Frequently Asked Questions
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MACRA (Medicare Access and CHIP Reauthorization Act) is a federal legislation signed into law in 2015. It affects healthcare reimbursement because it repeals the sustainable growth rate (SGR) formula which determines Medicare reimbursements; it creates a new framework for rewarding health care providers for giving better care; and it combines existing quality reporting programs into one new system.

The Quality Payment Program implements key provisions of MACRA by introducing new ways to reimburse physicians who provide care for Medicare Part B beneficiaries, shifting from the current fee-for-service model to value-based care. The Quality Payment Program establishes two reimbursement tracks: Merit-based Incentive Payment System (MIPS) and Advanced APMs (AAPM).

CMS was required to initiate the measurements for MIPS and Advanced APMs from Jan 1st, 2017. The provider performance, as measured in 2017, will impact the reimbursements they receive in 2019.

The majority of clinicians who bill Medicare Part B are impacted by the Quality Payment Program. CMS is also inviting commerical payers to join the MIPS model in upcoming years.

Familiarize yourself with MACRA and the pick your pace options for performance under MIPS in 2017. If you haven’t reported data on quality measures through the Physician Quality Reporting System (PQRS) or as part of meaningful use, start as soon as possible. If you submitted quality data during the last calendar year, you should access your Quality and Resource Use Report (QRUR). This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement. If your practice doesn’t provide chronic care management (CCM) services, consider the cost-benefit opportunity for increasing revenue to support needed practice transformation or quality improvement projects. Medicare began paying for CCM codes on January 1, 2015. You'll need to send in your performance data by March 31, 2018 in order to avoid negative payment adjustments in 2019. You can also begin participating in an Advanced APM.

CureMD has a Quality Payment Program consulting team that can assist. Please call 718-213-4870 or e-mails us at macra@curemd.com

The Merit-based Incentive Payment System (MIPS) is one of two new payment tracks established by MACRA. It combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program into a single program. Eligible Clinicians will be scored on quality, cost, improvement activities, and meaningful use of certified EHR technology and a threshold set by CMS will determine whether clinicians receive a positive [bonus] or negative [penalty] payment adjustment.

An eligible clinician (EC) is an individual physician or health care provider who is eligible to participate in, or is subject to, mandatory participation in a Medicare or Medicaid program. Under MIPS, an EC for the first two years of the program includes physicians (MD/DO and DMD/DDS), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. After the first two years, physical/occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists and dietitians/nutritional professionals will also be considered as ECs.

The composite performance score is the aggregate of an eligible clinician's scores in the four performance categories (quality, cost, advancing care information, improvement activities). The score will be compared to a yearly threshold that CMS will set and determine either a positive, negative or neutral payment adjustment. Under MIPS, payment adjustments will start from 4% in 2019 and gradually incease to 9% by 2022.

Providers in their first year with Medicare and those with a low volume of Medicare payments or patients (less than 100 patients or less than $30,000 Medicare Part B allowables) are exempted. Providers who qualify for payment under Advanced APMs are also exempted from MIPS.

Only 6 measures are required instead of 9 under PQRS, one of which should be an outcome measure. If an outcome measure is not applicable, a high-priority measure can be reported instead.

Under the Medicare EHR Incentive Program, each measure was reported and weighted equally. Under ACI, objectives are customizable and physicians can choose measures to emphasize in their scoring. In addition, ACI measures place an emphasis on patient engagement and interoperability.

An APM is a new approach to paying for medical care through Medicare that incentivizes quality and value. As defined by the law, APMs include: the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center Model, Medicare Shared Savings Program (MSSP), demonstration under the Health Care Quality Demonstration Program, or a demonstration required by federal law.

An Advanced Alternative Payment Model (AAPM) is an APM that has met the statutory APM requirements, as well as three additional criteria: (1) the APM must require participants to use certified EHR technology, (2) the APM must provide payment for covered services based on quality measures comparable to those in the quality performance category under MIPS, (3) the APM must either require APM entities to bear risk for monetary losses of more than a nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. The proposed rule identifies five AAPMs for the first performance period: Comprehensive ESRD Care (CEC) through a large-dialysis organization arrangement, Comprehensive Primary Care Plus (CPC+), Medicare Shared Savings Program (MSSP) Tracks 2 and 3, and Next Generation ACO Model.

Advanced APMs will receive an annual 5% bonus based on your Medicare Part B payments. This is in addition to the bonuses or penalties that are part of the specific Advanced APM which your are participating in. You will also be exempted from MIPS reporting and the subsequent adjustments. In the long run, successful participation in an Advanced APM has a huge financial upside.

In 2017, most physicians will be required to participate in MIPS. To participate in an AAPM, you should be a involved with in a MSSP or CPC+ and meeting the patient and revenue thresholds under the AAPM.

CMS has an created https://qpp.cms.gov/ and it is an excellent resource for those looking to learn about MACRA and the Quality Payment Program. Additionally, most provider associations such as the AAFP have created dedicated sections for MACRA on their websites [http://www.aafp.org/practice-management/payment/medicare-payment.html]. A lot of specialty specific detail can be found there.

There is $20 million a year allocated to provide technical assistance to practices with 15 or fewer eligible clinicians participating in MIPS. This assistance is intended to assist practices in a successful transition into the MIPS payment pathway. Priority will be given to practices in rural areas, health professional shortage areas (HPSAs), and medically-underserved areas.

Clinicians without an EHR can still participate in MIPS, but will not be eligible for any of the points under the ACI performance category. For 2017 ACI constitutes 25% of the total score, so not using an EMR makes it significantly difficult to score better than your peers.

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