Posted on 12 Oct, 2017 |comments_icon 4|By Elizabeth

MACRA, as you’re probably aware, is essentially a Quality Payment Program (QPP)—one that has streamlined the numerous quality improvement programs most coders have been involved with over the years. Among its objectives, MACRA is designed to reward healthcare providers for giving better quality of care and lowering their cost. On the flip side, MACRA will penalize those practitioners who do not align with the program.

Medicare Access and CHIP Reauthorization Act (MACRA)

  • Began in 2015 and will continue beyond 2021
  • Quality Payment Program ‘QPP’ – Streamlines multiple quality reporting programs to reward healthcare providers for giving better care
  • MACRA QPP includes MIPS ‘Merit-based Incentive Payment System’ – which combines the prior programs of *PQRS, VM, and Meaningful Use into four new performance categories on which provider quality will be measured.
  • MIPS categories will be measured starting in 2017 and the data will impact provider reimbursement in 2019.

Take Two: The Quality Payment Program (QPP)

Participation in MACRA involves two primary options. The first is the Advanced Alternative Payment Model, referred to as Advanced APMs. The second option, which most providers fall under, is the Merit-based Incentive Payment program (MIPS). Both programs allow practitioners to earn incentive payments through participation, and all eligible practitioners must join one of the programs, though options may include an ACO or other type of model.

Nail Down QPP Primary Options – AAMP and MIPS

  • Advanced Alternative Payment Model ‘APMs’ – may earn incentive payment for participating in an innovative payment model. Must join an AAPM
  • Merit-based Incentive Payment Systems ‘MIPS’- may earn a performance-based payment adjustment for participating. Must bill Medicare more than 30k in Part B charges annually and provide care for more than 100 Medicare patients yearly.
  • Most providers will fall under the MIPS model.

MACRA’s MIPS program expands on the existing PQRS quality reporting methods, such as registry, electronic health records (EHR), and Qualified Clinical Data Registry (QCDR), to allow for reporting measures across the MIPS categories of Quality, Advancing Care Information, and Improvement Activities. It also reduces the potential negative payment adjustments and streamlines the overall requirements. The main point is that MIPS replaces how practices were reimbursed under Medicare Part B. As a merit-based program, MIPS participants will receive reimbursement based on the quality of services rather than the number of services.

MIPS Fast Facts

  • First performance period January 1, 2017 – December 31, 2017
  • Records quality data and use technology to provide care
  • Data must be submitted to CMS by March 31, 2018 to receive a 5% incentive
  • payment
  • CMS will provide performance feedback
  • Incentive payments in 2019 for 2017 data
  • Data submitted will adjust your 2019 Medicare payments up, down or will not
  • change
  • Submit minimum data – will avoid a negative payment adjustment
  • Submit 90 days of data – will earn a neutral or positive payment adjustment
  • Full – submit a full year of 2017 data – may earn a positive payment adjustment

To qualify for MIPS participation’s and be eligible for performance-based incentive payments, you must bill Medicare for more than $30,000 in Part B charges annually and provide care for more than 100 Medicare patients yearly. You also must be either a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified registered nurse anesthetist. In 2019, this list of practitioners may broaden to include other categories of practitioners, such as PT, OT, and various types of billable providers.

The first MIPS performance period started on January 1, 2017 and will continue to December 31st. Payment adjustments are earned by demonstrating that you provided high quality, efficient care supported by technology by sending in information in the areas of Quality, Advancing Care Information, Improvement Activities, and Cost.

Providers must submit data to CMS by March 31, 2018 to receive a potential 5% incentive payment. CMS will then provide performance feedback, likely in a quadrant layout where the four quadrants would be high performance, low cost, low performance, high cost. Scoring in the high performance and low-cost quadrants will receive enhanced reimbursement in 2019. Scoring in the low performance and high cost quadrants will receive a reimbursement cut, or penalty, in 2019.

MIPS Performance Categories

  1. Quality (60%) – report at least 6 quality measures for at least 90 days
  2. Quality Improvement Activities (15%) – report via attestation completion of at least 4 improvement activities for a minimum of 90 days
  3. Advancing Care Information (25%) – replaces Meaningful Use. Fulfill 5 defined measures for a minimum of 90 days
  4. Cost – replaces Value-Based Modifier. Data submission is not needed. Calculation is based upon submitted claims

While you might not be prepared to take MIPS by storm at this date, if you submit minimum data for 2017, the first year of the program, you can avoid penalty. Practitioners who aren’t exempt from MIPS will receive a negative 4% payment adjustment if they fail to report data for 2017. Practitioners can earn a neutral or positive payment adjustment if they report 90 days of 2017 data. Finally, if practitioners send in data for the entire year, they increase their odds of earning a positive payment adjustment.

Again, opting not to participate in MIPS is a bad idea. Those who don’t participate will receive a negative payment adjustment in 2019 of 4% for Medicare Part B payments.

To learn more about MACRA—and to stay on track for optimum reimbursement with strategies to avoid payment cuts in the coming years—pick up your copy of Guidebook to Medicare Access and CHIP Reauthorization Act of 2015.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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