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MACRA and the Quality Payment Program

 

MACRA and the Quality Payment Program

Transitioning from a volume-based payment system to one that rewards value.

 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law on April 16, 2015. The law provides a more predictable Medicare payment schedule for physicians and other clinicians with intentions of moving from a volume-based system to a system that rewards value. This new payment system is called the Quality Payment Program (QPP).

Read how ACP advocated on behalf of clinicians and influenced the MACRA Rules:

MORE ACP ADVOCACY ON QPP

MACRA Physician


2019 (Year 3) - Qualification

The Quality Payment Program rewards value rather than volume. 2019 is Year 3 of the program. Physicians participate in one of two payment tracks to avoid penalties and earn potential increases in Medicare payments—the Merit-Based Incentive Payment System or an Alternative Payment Model. Physicians, or their practices, can decide annually the program in which they will be participating.

Excluded individuals or groups must meet one of the following criterion:
  • ≤ $90,000 Part B allowed charges OR
  • ≤ 200 Part B patients OR
  • ≤ 200 covered professional services under the PFS

Clinicians, groups or APM Entities may "opt-in" to MIPS if they meet 1-2 criteria (but not all 3). 

Check Participation Status

 

Selecting the right payment track

MIPS

Merit-Based Incentive Payment System

The Merit-Based Incentive Payment System (MIPS) builds on traditional fee-for-service payments by adjusting them based on a physician’s performance. Learn more

APMs

Alternative Payment Models

APMs structure payment to incentivize quality and value. “Advanced APMs” satisfy advanced risk, quality, and technology requirements and offer possible exclusion from MIPS and a 5% Medicare bonus. Two new primary care models will qualify as Advanced APMs starting in 2020. Learn more


Have more questions?

MACRA and the resulting Quality Payment Program are very comprehensive, and oftentimes confusing topics that affect all types of clinicians participating in Medicare Part B. If you still have questions or need further guidance, try this printable presentation or email macra@acponline.org.

Additionally, the Center for Medicare & Medicaid Services has both high level and detailed resources to assist you in navigating the rules and requirements and is easily sorted by program year, performance category, track (APM or MIPS), and resource type. Visit the CMS resource library.

We also encourage you to discuss QPP with your colleagues in the Member Forum on MACRA.

Quality Payment Program (QPP) for 2019

Finalized in October 2016, the Quality Payment Program (QPP) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), officially replacing the old Sustainable Growth Rate system. The new QPP transforms Medicare physician compensation, moving away from fee-for-service billing and toward payment based on value.

Understanding QPP is crucial for clinicians who participate in Medicare Part B. The below chart will help you determine if you quality for QPP in 2019.

Do you qualify?

YES
NO
Medicare Part B payments
Medicare Part A (e.g., hospital payments)
Physicians, PAs, NPs, CNSs, CRNAs, PTs and OTs, clinical psychologists, audiologists, speech & language pathologists, and registered dietitians or nutrition professionals.
Clinicians that fall below the low-volume threshold*
Groups that include the above clinicians
Clinicians billing Medicare for the first year (for MIPS)

*If you bill Medicare less than or equal to $90,000 a year OR provide care for less than or equal to 200 Medicare patients a year OR less than or equal to 200 professional services to Part B patients. However, clinicians or groups who qualify for one or two of the low-volume thresholds may "opt-in" to MIPS in 2019.

If you do qualify to participate in QPP, you will need to decide which payment track to follow - the Merit-based Incentive Payment System or an Alternative Payment Model.

Check your participation status in either MIPS or APM. After groups log into their EIDM account, they can click into a detailed listing of the eligibility status of every NPI in the group to find out if they are a 2018 MIPS participant.

Please note that additional details regarding the 2019 performance year will be added as they become available.