The first measurement period for the Medicare Quality Payment Program under MACRA began January 1, 2017. Below you can find an outline of the basics of the program to help you prepare. Able Health will update this summary continuously as new information becomes available.
Recent MACRA legislation introduced a new Medicare value-based reimbursement system that will impact Medicare reimbursement amounts beginning in 2019. This new system, called the Quality Payment Program (QPP), repeals the Sustainable Growth Rate Formula and is made up of two participation tracks—the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). If you are a clinician that bills services under the Medicare Physician Fee Schedule, understanding the requirements and payment changes under MACRA is very important since payment adjustments that occur in 2019 will be based on action and performance starting January 1, 2017.
The following tabs outline what you need to know for participation in MIPS and APMs under MACRA:
The Merit-Based Incentive Payment System (MIPS) is a Medicare value-based payment system that combines three current Medicare programs that are scheduled to sunset at the end of 2016. The new system will evaluate the performance of all MIPS eligible clinicians or eligible groups across four performance categories in order to determine payment adjustments that will be applied in future years: Quality, Cost, Advancing Care Information, and Improvement Activities.
The first MIPS performance year is January 1, 2017 - December 31, 2017, and payment adjustments accrued from that performance year will be applied to Medicare Part B reimbursements beginning on January 1, 2019. In response to feedback from stakeholders and healthcare providers, CMS has designated the 2017 performance year a transition year, with reduced requirements that encourage broad successful participation by MIPS eligible clinicians.
Does your medical group understand the requirements necessary to avoid a negative MIPS payment adjustment in the transition year and beyond? Are you prepared to begin reporting for MIPS in 2017? Keep scrolling to find out how Able Health can help make your transition to MIPS participation seamless and successful.
Contribution to MIPS Performance Score
60% of MIPS Composite Score in 2017
0% of MIPS Composite Score in 2017
15% of MIPS Composite Score in 2017
25% of MIPS Composite Score in 2017
In 2017, providers can pick the pace of participation in the Quality Payment Program that fits them best, including three options for participating in the MIPS program.
|Participation Option||Payment Adjustment Impact|
|(1) Full MIPS Participation. Report all measures required under the MIPS program, in all performance categories that require reporting, for a full 90-day period or, ideally, the full calendar year.||Eligible for maximum positive adjustment. Clinicians who meet these requirements are maximizing their chance to qualify for a positive adjustment. Exceptional performers who achieve a MIPS Composite Performance Score of at least 70 out of 100 will be eligible for an additional positive adjustment from a bonus pool of $500 million.|
|(2) Partial MIPS Participation. Report more than one measure in the Quality category, more than one activity in the Improvement Activities category, or more than one of the required measures in the Advancing Care Information category for at least a full 90-day period.||Avoid a negative payment adjustment and be eligible for a positive payment adjustment. Clinicians who meet these requirements will avoid a negative payment adjustment and potentially earn a positive payment adjustment in 2019.|
|(3) Minimum MIPS Participation. Report one measure in the Quality performance category, report one activity in the Improvement Activities performance category, or report the required measures in the Advancing Care Information performance category.||Avoid a negative payment adjustment only. Clinicians who meet these requirements will meet the 2017 MIPS performance threshold (3 points) and avoid a negative 4% payment adjustment in 2019. With this level of participation, there will be no opportunity to earn additional incentive payments.|
|(4) Participate in an Advanced APM. Participate in an Advanced APM in 2017 and meet the minimum Qualifying Participant payment or patient requirements.||Potentially earn the Advanced APM positive payment incentive. MIPS eligible clinicians participating in one or more Advanced APMs who receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM(s) will qualify for a 5% bonus incentive payment in 2019.|
Alternative Payment Models (APMs) offer new ways for CMS to pay health care providers for the care they give Medicare beneficiaries. Clinicians who take a further step towards care transformation by participating to a sufficient extent in an Advanced APM are exempt from MIPS payment adjustments and can qualify for a 5% Medicare Part B incentive payment each year.
The base definition of an Alternative Payment Model (APM) includes:
Advanced APMs are those that meet the base definition of an APM under MACRA and also meet the following criteria:
Because many APMs offer different tracks or options within the same model, CMS has finalized the proposal to consider different tracks or options within an APM separately for the purposes of determining whether the track or option meets the Advanced APM criteria. CMS will release an initial set of Advanced APM determinations for APMs that will be operating during the first Qualifying Participant Performance Period no later than January 1, 2017.
MIPS APMs are APMs that enable participating eligible clinicians and groups to leverage the MIPS APM scoring standard. MIPS APMs must meet the base definition of APMs as well as the following criteria:
Note that CMS has indicated that there may be MIPS APMs that would not be able to use the MIPS APM scoring standard due to technical or resource issues (e.g. the performance period ending earlier than the MIPS performance period).
MACRA sets thresholds for the level of participation in Advanced APMs that are required for an eligible clinician to become a Qualifying Participant (QP) or Partial Qualifying Participant (Partial QP) for a given year. Eligible clinicians who meet Qualifying Participant requirements during the Qualifying Participant performance period are exempt from MIPS participation and will earn a 5% incentive payment. Partial QPs have the option to participate in MIPS will not earn an incentive payment for their Advanced APM participation.
QPs and Partial QPs must meet one of the following thresholds as it relates to participation in an Advanced APM during the 2017 performance year to be exempt from MIPS:
|QP Threshold||Partial QP Threshold|
|Medicare Payment Amount1||25%||20%|
|Medicare Patient Count2||20%||10%|
1The Medicare Payment Amount percentage is defined as (All payments for Medicare Part B covered professional services furnished by the eligible clinicians in the Advanced APM Entity to attributed beneficiaries during the QP Performance Period/all payments for Medicare Part B covered professional services furnished by the eligible clinicians in the Advanced APM Entity to attribution-eligible beneficiaries during the QP Performance Period) * 100
2The Medicare Patient Count percentage is defined as (The number of unique attributed beneficiaries to whom eligible clinicians in the Advanced APM Entity furnish Medicare Part B covered professional services during the QP Performance Period/The number of attribution-eligible beneficiaries to whom eligible clinicians in the Advanced APM Entity furnish covered professional services during the QP Performance Period) * 100
Download, print, and share the following free reference sheets to keep the most important information about MACRA, MIPS, and APMs close at hand.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in April 2015 and put into place three important changes to how Medicare pays providers who deliver services to Medicare beneficiaries:
Implementation details for many components of MACRA were finalized in October 2016 as part of the “Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models” final rule with comment period.
The Quality Payment Program (QPP) puts into place key aspects of the MACRA by establishing a new framework for rewarding health care providers for the quality of services delivered to patients instead of just the quantity and combines existing quality reporting programs into one new system. Implementation details for the QPP were finalized in October 2016 as part of the CMS final rule “MIPS and APM Incentive under the Physician Fee Schedule.” The QPP offers two payment tracks for participating providers: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
The Merit-Based Incentive Payment System (MIPS) is one of the two tracks of the Quality Payment Program and combines the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Medicare EHR Incentive Program (Meaningful Use) into one program that measures eligible clinicians on four different performance categories: Quality, Cost (Resource Use), Advancing Care Information (which evaluates the meaningful use of certified EHR technology), and Improvement Activities (previously referred to as Clinical Practice Improvement Activities).
Results from the four MIPS performance categories are translated into points, which are combined into a single performance score called the MIPS Composite Score. The MIPS Composite Score is used to determine payment adjustments. During the 2017 performance year, CMS has finalized that the Resource Use (Cost) performance category will have a weighted value of 0%, so in 2017, the MIPS Composite Score will be determined based on performance in the other three performance categories.
Alternative Payment Models (APMs) are new ways to pay healthcare providers for the care that they deliver to Medicare beneficiaries. MACRA defines any of the following as a qualifying Alternative Payment Model (APM):
Advanced APMs are APMs that meet additional criteria related to infrastructure, provider payments, and risk. To qualify as an Advanced APM, a payment model must meet the definition of an Alternative Payment Model (APM) under MACRA and also:
An eligible clinician receiving the designated percentage of Medicare payments or patients through an Advanced APM can be considered a Qualifying Participant (QP) or Partial Qualifying Participant (Partial QP), which exempts the provider from the MIPS payment adjustment and makes them eligible for a 5% Medicare Part B incentive payment.
Under the first two years of MACRA, a MIPS eligible clinician be defined as the following licensed providers and any group that includes such professionals:
The above clinicians would be subject to payment adjustments beginning in 2019 if they do not successfully participate in MIPS, meet Advanced APM QP requirements, or meet other exclusion requirements in 2017. In future years, the list of MIPS eligible clinicians could expand to include the following clinicians:
CMS has finalized that the following clinicians will be excluded from the MIPS payment adjustment:
Be the first to know about key MACRA information, deadlines, and expert analysis. Below is a sample of recent updates and commentary.