What is the Medicare Access and CHIP Reauthorization Act (MACRA)?
MACRA is legislation passed in 2015 by Congress. MACRA eliminates the sustainable growth rate, but preserves fee-for-service payments. MACRA consolidates several quality-reporting programs into a single system, the Quality Payment Program (QPP). This system has two tracks:
- the Merit-Based Incentive Payment System (MIPS)
- the Advanced Alternative Payment Model (AAPM).
Under MACRA, physicians can choose to participate in either of the two tracks. Based on their 2017 performance in MIPS or an APM, physicians will receive positive or negative Medicare payment adjustments beginning in 2019.
What track will most clinicians fall into?
Based on CMS calculations, 83 to 90 percent of eligible clinicians will fall into the MIPS track in 2017, while only 10 to 17 percent of clinicians will fall into the Advanced APM track.
How will MACRA impact my Medicare payments?
Under MACRA, all physicians will receive a 0.5 percent update to the annual conversion factor (before sequestration or adjustments due to impacts from budget neutrality factors) from 2016 through 2019. For 2020 to 2025, no update is guaranteed. Physician updates will be based on performance in either the MIPS or the APM track. Physicians will then receive that track’s associated bonus or penalties.
What are the exemptions from MIPS?
For the CY 2017 performance year, there are only three exemptions from MIPS for clinicians who otherwise meet the eligibility requirements above:
- Clinicians in their first year of Medicare Part B participation
- Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for up to 100 Part B patients in one year
- Clinicians in entities sufficiently participating in an Advanced APM
Is there any relief for solo, small, and rural practices?
The final rule, as noted above, exempts from reporting requirements for 2017 practices with $30,000 or less in Medicare Part B charges or 100 Medicare patients or fewer, or who will be in their first year of Medicare participation. The earlier version of the rule set the exemption threshold for Medicare charges at $10,000 or less and 100 or fewer patients.
Most small practices are expected to choose the MIPS track, and the final rule allows for more choices in how they report their data in 2017. They can either submit a minimum amount of information, such as an individual quality performance measure or clinical improvement activity; data covering 90 days or more and more than one quality measure or improvement activity; or a full year of data. The final rule also reduces by about half the number of required reporting measures. There are additional reduced reporting requirements for small, rural, and health professional shortage area clinicians across several of the MIPS categories.
If I am in an alternative payment model (such as an ACO), do I still have to participate in MIPS?
Only APM participants who successfully participate in an advanced APM, assuming they meet the required thresholds, will be exempt from MIPS. The majority of physicians will only be eligible for MIPS. This includes many APM participants.
You must participate in MIPS if your APM does not qualify as an advanced APM. You must participate in MIPS if you cannot meet the thresholds for advanced APM participation. However, participation in an APM may help you meet some of the MIPS reporting requirements. These requirements include quality reporting and clinical practice improvement.
What if I am choosing to not participate in MIPS or an APM?
Some physicians — for example, those planning to retire in the near future — may choose not to participate in MIPS or an APM. These physicians can continue to see Medicare patients. They will receive fee-for-service-based payment for treating these patients. However, they will also experience reduction in their Medicare payments two years later. These payments will be reduced by the amount of the maximum MIPS penalty. In 2019, the maximum penalty will be four percent. It will increase to nine percent in 2021.
Is there a group reporting option for MIPS?
Yes. If a practice reports at the group level for one MIPS category, it must do so for all four categories of the program.
Should we report at the individual clinician or group practice level?
While each practice is different, there may be benefits to reporting for MIPS at the group practice level (TIN) if there are multiple eligible clinicians in the practice. There is no registration process for practices that wish to report at the group level. If you participate as a group or individual, you must do so for all categories. You cannot report at different levels for each category.
Without an EHR, is it possible to participate in MIPS?
Clinicians without an EHR can still participate in MIPS, but will not be eligible for any of the points under the Advancing Care Information (ACI) performance category. This will negatively affect the clinician’s total composite score. If you do well on the quality and clinical practice improvement activity categories, you could potentially earn a score high enough to be eligible to earn a bonus.
Should those of us without EHR apply for a hardship exemption?
Yes. Under MIPS, hardship exemptions are available for MIPS-eligible clinicians who cannot comply with the advancing care information category because of a significant hardship. CMS will announce the application process at a later date.
Should those of us without EHR apply for a hardship exemption?
Yes. Under MIPS, hardship exemptions are available for MIPS-eligible clinicians who cannot comply with the advancing care information category because of a significant hardship. CMS will announce the application process at a later date.
Will MIPS performance data be made available publicly?
Yes. CMS will publish clinician and group performance on either the Physician Compare website or CMS downloadable database. CMS will allow a 30-day preview period in advance of the publication of any data on Physician Compare to allow clinicians to review and submit corrections before information is made public.
Miranda Franco is senior public affairs advisor for Holland & Knight LLP. Questions or comments related to this article should be directed to Miranda.Franco@hklaw.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.