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Ensure payment and avoid policy violations. Plus, new resources to help you navigate the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
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Understand your options under the Quality Payment Program (QPP) that was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Learn how to succeed in either of the two payment tracks. Find answers to commonly asked MACRA and Quality Payment Program questions below.
The Medicare Access and CHIP Reauthorization Act of 2015 was signed into law on April 16, 2015, and became final in October 2016. The law eliminated the sustainable growth rate (SGR) formula that had previously been used to calculate Medicare payments to physicians and had resulted in repeated threats of severe payment cuts. The law provides a more predictable Medicare payment schedule for physicians and other clinicians, while moving the payment system away from a volume-based system toward a system that rewards value.
The Quality Payment Program (QPP) is the name for the Medicare Part B physician payment system that was established by the MACRA law. The final rule implementing the QPP, issued in October 2016, incorporates many improvements to policies that were initially proposed based on comments received from ACP and others. Our suggestions to CMS paid particular attention to how small practices and subspecialists can succeed in the new program.
Starting in 2017 physicians will begin participating in either the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM) to earn additional increases in their Medicare payments in 2019. Physicians, or their practices, will have the opportunity to decide annually the program in which they will be participating.
MACRA applies to all physicians and other certain other types of clinicians (nurse practitioners, physician assistants, certified registered nurse anesthetists, and clinical nurse specialists) who participate in Medicare Part B, unless they meet one of the exclusion criteria.
There are three groups of physicians and other clinicians who will not be subject to MIPS:
In 2017, CMS is allowing ECs to “pick their pace” by creating different levels of participation to allow flexibility during the transition year. If an Eligible Clinician is not in any type of APM arrangement, during 2017 there are three paths to participation in MIPS:
Note: During 2017, the transition year, there will be no negative adjustments as long as one of the above options is chosen. However, practices are encouraged to participate to the fullest extent possible to prepare for participation in 2018 and onward.
The Merit-Based Incentive Payment System (MIPS) builds on traditional fee-for-service payments by adjusting them up or down based on a physician’s performance in a new reporting system. This new reporting system will combine several existing Medicare reporting programs; the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program (also known as Meaningful Use), and the Value-Based Payment Modifier Program—and also adds in a new component, Improvement Activities.
In Year 1 (2019 payments based on 2017 performance) physicians participating in MIPS will receive a composite score based on four weighted categories:
These categories will be combined into one number called the MIPS Composite Performance Score.
MIPS payments will be the Medicare base rate (described above) in addition to a physician’s composite performance score adjusting his or her payments up or down.
Payments can never be reduced by more than the level set in the law. However, in order to make the adjustments budget neutral, the upward adjustments may have a scaling factor applied to make the total upward and downward adjustments equal to each other.
Additionally, physicians who are determined to be an exceptional performer will be eligible to receive an additional positive payment adjustment of up to 10 percent. This exceptional performance payment adjustment is not budget neutral but will come from a separate designated fund.
Alternative Payment Models (APMs) are a new approach to paying for medical care that incentivizes quality and value. According to the law, initially Medicare APMs will include:
Some APMs will qualify as “Advanced APMs." Over time, additional types of Advanced APM options will become available. Advanced APMs largely involve accepting risk based on the quality and effectiveness of care provided, like in an accountable care organization (ACO). However, Medical Homes (initially as expanded under the CMS Innovation Center—currently there are none) can qualify as an APM without taking on financial risk.
Some APM participants will qualify to receive an additional 5% lump sum payment and a higher fee schedule in future years. For 2017, only participation in the following programs will qualify as Advanced APMs:
Over time, as CMS modifies and expands the criteria, more models will qualify as Advanced APMs. ACP is working to expand the options for advanced APMs, especially so that it will be easier for small practices to participate.
As noted above, an APM is defined as a new approach to paying for medical care through Medicare that incentivizes quality and value. However, not all APMs are “Advanced APMs.” Advanced APMs meet the following criteria:
Qualifying APM participants (or QPs) are the clinicians who have a certain percentage of their patients or payments through an eligible Advanced APM.
Physicians who participate in an APM that is not determined to be an Advanced APM will be participants in the MIPS program; however, they will receive favorable scoring under MIPS.
Those that participate in an Advanced APM—i.e., physicians who are QPs—will:
Not all clinicians in an Advanced APM will qualify – they must have a certain number of patients or payments from the Advanced APM. The proposed thresholds are a calculated ratio and increase each year of the program.
Check to see if you are a member of any of the following entities that qualify:
Eligible clinicians can participate in MIPS either as an individual or under the TIN of their group. If reporting as a group, all clinicians with NPIs assigned to the TIN must participate as a group and report on the same measures and activities.
See ACP’s list of 10 things to do for MACRA.
Patient-Centered Medical Homes (PCMHs) are strongly incentivized under both pathways in the following ways:
However, as defined by the rule, for a Medical Home Model to be defined as an Advanced APM, it must have the following features:
You could also begin to investigate if there are APM options in your area that are underway or being initiated by private payers or other stakeholders—getting involved in these programs, which could provide some supports and helpful services to transition to a more value-based payment system, may be beneficial to your success in either MIPS or APMs down the line.
No. This program only applies to Medicare Part B fee-for-service at this time. However, some APMs may include Medicaid and private payer models in the future.
As the current rule is written, it does restrict larger groups (>50 clinicians) in CPC+ from qualifying as an Advanced APM beginning in 2018. This is generally, CMS defines this as limiting the Advanced APM designation in CPC+ to those practice sites that are part of a parent organization with 50 or fewer eligible clinicians. CPC+ practices that are part of a parent organization with more than 50 eligible clinicians may participate in CPC+ but will not receive the Advance APM designation or the additional 5 percent bonus associated with Advanced APMs.
ACP members can post a question or comment in the College’s MACRA forum or email ACP staff at email@example.com.
CMS also maintains a QPP support center. Questions can be directed to QPP@cms.hhs.gov or 1-866-288-8292.
Updated March 2017