If you are a Medicaid/Medi-Cal Meaningful use EP, the following information regarding MACRA and MIPS does not apply to you. Please click here to go to the Meaningful Use Resources webpage.
This information is based on Public Law 114-10 signed into law on April 16, 2015 and CMS documents/materials published on CMS.gov as of July 6, 2016.
Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA)
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was enacted on April 16, 2015. MACRA replaces the flawed Sustainable Growth Rate (SGR) formula with a new approach to paying Eligible Clinicians (ECs) for the value and quality of care provided to patients. MACRA implements these changes through the unified framework called the “Quality Payment Program” which includes two tracks: The Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). In order to determine whether clinicians meet the requirements for the Advanced APM track, all clinicians will report through MIPS in the first year. The proposed rule provides flexibility for participating in MIPS and makes it easy for clinicians to move between the components of the MIPS track or the Advanced APM track.
The Merit-Based Incentive Payment System (MIPS)
MIPS will streamline how Medicare measures value and quality of care by doctors and other clinicians by streamlining three independent programs: Physician Quality Reporting Program (PQRS), Medicare EHR Incentive Program – Meaningful Use (MU), and Value-Based Payment Modifier Program.
ECs will have a composite performance score calculated on the following categories:
- Quality (50%) – replaces the Physician Quality Reporting System (PQRS) and the quality component of the Value-Based Payment Modifier Program
- Advancing Care Information (ACI) (25%) – replaces the MU Incentive Program
- Clinical Practice Improvement Activities (15%) – EPs may select activities from a list of more than 90 options. Activities will be weighted. Highly weighted activities will be worth 20 points
- Cost (10%) – replaces the cost component of the Value-Based Modifier (VBM) Program
Based on the EC’s composite performance score, the EC will receive a positive, negative or neutral payment adjustment between +4 and +9%.
CMS will begin measuring performance for ECs beginning on January 1, 2017, with payments based on measures beginning in 2019. This means that the last reporting period for PQRS, Medicare EHR Incentive Program, and Value-Based Payment Modifier Program will be January 1, 2016 – December 31, 2016.
Measures and final rules will be released no later than November 1, 2016.
Alternative Payment Models (APMs)
ECs sufficiently participating in an Advanced Alternative Payment Model (APM) would be exempt from the MIPS payment adjustments and would qualify for a 5% Medicare Part B incentive payment. To be exempt from MIPS payment adjustment and qualify for the incentive payment, ECs must have a certain percentage of their payments or patients through an Advanced APM.
The list of models that would qualify under the terms of Advanced APMs include:
- Comprehensive ESRD Care Model (Large Dialysis Organization arrangement)
- Comprehensive Primary Care Plus (CPC+)
- Medicare Shared Savings Program – Track 2
- Medicare Shared Savings Program – Track 3
- Next Generation ACO Model
- Oncology Care Model Two-Sided Risk Arrangement (Available in 2018)
The list of models that would qualify would be updated annually as existing models are modified or new models are developed. Beginning in performance year 2019, ECs could quality for incentive payments based on participation in Advanced APMs developed by non-Medicare payors, such as private insurers or state Medicaid programs.
Eligibility to Participate in MIPS
MIPS applies to Medicare Part B physicians (MD/DO, DMD, DDS), including physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.
Exemptions from participation in MIPS and the payment adjust include:
- ECs that are in their first year of Medicare Part B participation
- ECs that have less than $10,000 in Medicare charges and less than 100 Medicare patients in one year
- EC is participating in an Advanced APM
Current Meaningful Use Participants
If you are a current Medicare provider participating in Meaningful Use, click here to see how MIPS impacts your future reporting and payment adjustments.
To find out how The Gap Group can help you successfully navigate MIPS participation, please email us at ContactUs@thegapgroup.com.
Patient Surveys
MIPS and Patient Surveys – Performing patient surveys will result in higher scores in two of the categories. To find out how The Gap Group can help you with your patient surveys, click here.
