MACRA and MIPS: An Overview

MACRA is the Medicare Access and CHIP Reauthorization Act. It was signed by President Obama into the law on April 26, 2015. MACRA revokes the previously used Medicare reimbursement formula with a new pay-for-performance program that prioritizes accountability, value, and quality. It provides a more sustainable payment framework for both providers and physicians. According to the Medicare and Medicaid Services (CMS), MACRA implements a new payment system that gives rewards to healthcare providers for giving better care instead of more service.

A Quality Payment Program (QPP) that implements MACRA, establishes two tracks for physicians:

  • The Merit-based Incentive Payment System (MIPS) to measure physician’s performance
  • Advanced Alternative Payment Models (APMs) so they earn revenues from alternative pay models

MIPS: An Overview

MIPS is an acronym for the Merit-Based Incentive Payment System. It is among the two payment models in the Quality Payment Program that determines Medicare payment adjustments. The program aims to ensure better patient care while reducing the costs of care and is implemented by measuring the composite performance score of eligible professionals (EPs). EPs may receive a payment bonus, a payment penalty, no payment adjustment depending on their performance.

The Composite Performance Score depends on the following measurement criteria:

  • Quality
  • Clinical practice improvement activities
  • Resource use
  • Meaningful utilization of certified electronic health records (EHR) systems

MACRA Frequently Asked Questions

This article presents some thoroughly researched frequently asked questions regarding MACRA from MACRA certified healthcare professionals.

What is the Quality Payment Program?

The Quality Payment Program enacts the key provisions of MACRA. It introduces new approaches to compensate physicians who provide healthcare services for Medicare Part B beneficiaries. The program replaces the previously used fee-for-service model to value-based care. The QPP creates two payment paths for physicians: Advanced APMs (AAPM) and Merit-based Incentive Payment System (MIPS).

Who Participates in the QPP?

To participate in the QPP, the qualifying criteria are:

  • Bill Medicare for more than $30,000 in Part B and allowed charges for a year
  • Offer healthcare services to more than 100 Medicare patients a year
  • Are Advanced Alternative Payment Models (APM)
Who is impacted by the Quality Payment Program?

The clinicians who bill Medicare Part B will be influenced by this Quality Payment Program. However, CMS is also inviting commercial payers to be a part of the MIPS model in upcoming years.

How to prepare yourself for MACRA?

To prepare for MACRA in 2019, health systems and physicians have to determine the right strategies. Following are a few steps that can health systems on how to prepare for MACRA:

  • Outline a strategy to prepare for MACRA by Q4 2016.
  • Actively attend society meetings and take advantage of the insights they offer. Renowned physician groups including American of Family Physicians (AAFP) and American Medical Association (AMA) offer their services to train and guide physicians on MACRA. In addition to that, the American Hospital Association (AHA) also offers online services such as a webinar to help healthcare systems prepare for MACRA.
  • Enlighten providers and have detailed discussions regarding new regulation.
  • Get help from the health system thought leaders to discuss ACOs, etc.
  • Evaluate your CMS Quality Resource and Use Report (QRUR).
  • In case you did not report for meaningful use then asses the penalties for MACRA
  • Review your quality measure and spot your top-performing areas.
  • Take assistance from MACRA certified healthcare professionals
Are there any Exemptions for eligible providers?

There are many exemptions for eligible providers including:

  • being in the first year of Medicare for 2017
  • participation in Advanced APM
  • seeing less than 100 Medicare patients each year
  • bill $30,000 or less in Medicare

MIPS Frequently Asked Questions

Here are a few thoroughly researched frequently asked questions about MIPS.

What is MIPS Composite Performance Score?

This score is the aggregate of an eligible professional’s scores in the performance criteria categories including quality, cost, advancing care information, clinical practice improvement activities. The composite performance score is compared to an annual threshold that is set by the CMS and decides either a positive, negative or neutral payment adjustment. Under MIPS, payment adjustments start from 4% as of 2019 and eventually increase to 9% by 2022.

What needs to be reported for MIPS?

MIPS reporting depends on four performance categories. Eligible Clinicians will be given a composite score according to their performance. Performance criteria include:

The following two criteria categories are required to be reported for the full calendar year.

  • Quality:checks the quality of healthcare services, depending upon the measures concerning healthcare quality and outcomes of care. Quality holds 50% of the MIPS composite score.
  • Cost:Also measures the cost of the care provided, which is computed by CMS according to the EP’s Medicare claim data. Cost holds 10% of the MIPS composite score.

The other two categories are:

  • Advancing Care Information (ACI):It holds 25% of the MIPS composite score. ACI encourages the use of certified EHR technology to ensure modern-day patient care.
  • Clinical Practice Improvement Activities:It accounts for 15% of the MIPS composite score and encourages the ongoing improvement of clinical activities.
What are the incentives and penalties under MIPS?

As of the incentives, Eligible Professionals (EPs) can earn a progressive payment adjustment of about 5% on the Medicare Part B reimbursements according to their MIPS performance in 2018. EPs who neither participate nor meet the minimum performance thresholds will be given a -5% payment adjustment. Each year, positive and negative adjustments are scheduled for the program, and bonus rewards are given to the highest scoring EPs.

Are there any Exemptions under MIPS?

The exemptions under MIPS are:

  • Providers in their first year with Medicare.
  • Providers with a low volume of Medicare payments less than $30,000 Medicare Part B or patients less than 100.
  • Providers who are under Advanced APMs.

This article is a go-to guide for understanding MACRA and MIPS EHR certification criteria. We hope it will offer helpful insight to those looking to find out the basic details about MACRA and MIPS.

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