Five questions about MACRA, MIPS, and APMs that you haven’t asked…but should

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The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule that outlines steps for implementing MACRA legislation, and the agency is taking comments from the public through the end of this month. To help shed light on some of the more confusing aspects of the proposed rule, Able Health has compiled a selection of important questions and clear answers for your organization to consider as you prepare for the first MACRA performance period at the beginning of next year.

  1. I am a Medicare physician, but I don’t see patients in face-to-face visits. Am I still required to participate in MIPS?
  2. My physician group is preparing to report PQRS as a group for the 2016 year. Are the requirements under MIPS essentially the same as what we are preparing for this year?
  3. I’m a clinician participating in a program that CMS has designated as an Advanced Alternative Payment Model (APM). Does that mean I am automatically exempt from MIPS?
  4. My medical group is participating in a commercial-payer-administered Accountable Care Organization (ACO). Are we eligible to receive the 5% incentive bonus for participating in the Advanced APM track during the 2017 performance year?
  5. Okay, so if my commercial ACO doesn’t allow me to participate in the Advanced APM track, can we at least catch a break and meet the APM Scoring Standard under MIPS?

The proposed rule is extremely lengthy and complex—not unexpected for legislation that has to outline multiple brand new programs—but that doesn’t mean physicians are off the hook in terms of understanding what requirements they face next year to earn maximum Medicare reimbursements. Click through each of the questions, even if you think it doesn’t apply to you, and you might just learn something you didn’t know you needed to know!

1. I am a Medicare physician, but I don’t see patients in face-to-face visits. Am I still required to participate in MIPS?

Yes. CMS has proposed a category of MIPS eligible clinicians, called “non-patient-facing MIPS eligible clinicians,” who will have to meet a different set of requirements under MIPS than providers who see patients face-to-face on a regular basis.

CMS is proposing that non-patient facing MIPS eligible clinicians be individual MIPS eligible clinicians or groups that bill 25 or fewer patient-facing encounters during a performance period. CMS considers a patient-facing encounter as an instance in which the MIPS eligible clinician or group billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule. CMS plans to publish the proposed list of patient-facing encounter codes on a CMS website similar to the way they currently publish the list of face-to-face encounter codes for PQRS. It is important to note that CMS is proposing to include telehealth services in the definition of patient-facing encounters for the purposes of MIPS eligible clinician status.

2. My physician group is preparing to report PQRS as a group for the 2016 year. Are the requirements under MIPS essentially the same as what we are preparing for this year?

Screen Shot 2016-06-13 at 12.24.54 PMSort of. MIPS is a payment system that is comprised of four different performance categories (Quality, Resource Use, Advancing Care Information, and Clinical Practice Improvement Activities), whereas only one (Quality) is similar to PQRS. However, the Quality performance category requirement that clinicians must meet are only slightly different than what is required right now for PQRS.

Similarly to PQRS, CMS is proposing that clinicians have a choice of several different reporting methods under MIPS. For the registry, EHR, and qualified clinical data registry (QCDR) reporting methods, a clinician must typically report a minimum of six quality measures, where one measure is a cross-domain-cutting measure if the clinician is patient-facing, and one measure is an outcome measure (or a “high priority measure,” if an outcome measure is unavailable). CMS has included a list of high priority measures, defined as an outcome, appropriate use, patient safety, efficiency patient experience, or care coordination quality measure, in the proposed rule. The individual quality measures that clinicians can choose from are included in the proposed rule as MIPS Measures, but CMS is also proposing a number of specialty-specific measure sets as well. Clinicians who report the entire specialty-specific measure set that applies to them would not need to separately report a cross-cutting measure or an outcome measure.

In addition to the six quality measures or the specialty measure set that providers will report, CMS will also calculate population quality measures based on the Medicare Part B claims that are submitted throughout the performance year. Each measure in the MIPS Quality performance category (including measures reported to CMS by the clinician and population measures calculated by CMS) is assigned a maximum possible 10 quality points, which are assigned based upon the percentage results of that measure relative to national peer benchmarks.

Under PQRS, eligible professionals had to meet all the reporting criteria or be subject to a negative payment adjustment. However, in MIPS, CMS has proposed that MIPS eligible clinicians receive credit for any of the measures that they report, regardless of whether or not the MIPS eligible clinician meets all of the quality performance category submission criteria. That means that a MIPS eligible clinician who reports 4 of 6 measures can still earn points towards their MIPS Composite Score based on those 4 measures.

3. I’m a clinician participating in a program that CMS has designated as an Advanced Alternative Payment Model (APM). Does that mean I am automatically exempt from MIPS?

Not necessarily. Only Qualifying APM Participants (QPs) and Partial Qualifying APM Participants (Partial QPs), as defined by the proposed rule, are exempt from MIPS. The MACRA sets thresholds for the level of participation in Advanced APMs that are required for an eligible clinician to become a QP or Partial QP for a given year.

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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%

Unfortunately for APM participants, CMS will not confirm whether the above thresholds have been met until after the performance year ends. That means you could be subject to the payment penalties in 2019 if you do not prepare for 2017 MIPS reporting and don’t end up meeting the QP or Partial QP requirements.

Clinicians who are participating in an Advanced APM can use the APM Scoring Standard under MIPS in order to reduce the reporting burden required by MIPS and the APM. The APM scoring standard allows MIPS eligible clinicians to report certain data under MIPS regardless of whether they ultimately become QPs or Partial QPs through their participation in Advanced APMs. Although QPs (and Partial QPs who elect not to participate in MIPS) would be excluded from MIPS payment adjustments, CMS has stated that they believe it is necessary to treat these eligible clinicians as MIPS eligible clinicians unless and until the QP or Partial QP determination is made.

4. My medical group is participating in a commercial-payer-administered Accountable Care Organization (ACO). Are we eligible to receive the 5% incentive bonus for participating in the Advanced APM track during the 2017 performance year?

Most likely not. Commercially run alternative payment models like ACOs would fall under the definition of “Other Payer Advanced APMs”—not regular Advanced APMs—and CMS is proposing that participation in Other Payer Advanced APMs for the purposes of MIPS exemption not be applicable until the 2021 payment year (which aligns with the 2019 performance year). This could potentially change in the final rule, but it is unlikely.

The proposed rule says that to be an Other Payer Advanced APM, a commercial or Medicaid APM must meet three requirements similar to the CMS Advanced APM requirements:

  1. Require participants to use certified EHR technology;
  2. Provide payment based on quality measures comparable to those used in the quality performance category of MIPS; and
  3. Be either a Medicaid Medical Home Model that is comparable to Medical Home Models expanded by the Center for Medicare and Medicaid Innovation or bear more than a nominal amount of risk for monetary losses.

5. Okay, so if my commercial ACO doesn’t allow me to participate in the Advanced APM track, can we at least catch a break and meet the APM Scoring Standard under MIPS?

Unfortunately, no. CMS has proposed that the APM Scoring Standard under MIPS only apply to MIPS eligible clinicians in APM Entity groups participating in certain types of APMs that meet the criteria listed below, referred to as MIPS APMs:

  1. APM Entities participate in the APM under an agreement with CMS;
  2. The APM Entities include one or more MIPS eligible clinicians on an APM Participation List; and
  3. The APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality measures.

The APM scoring standard would not apply to MIPS eligible clinicians involved in APMs that include only facilities as participants (such as the Comprehensive Care for Joint Replacement Model). APMs that do not base payment on cost/utilization and quality measures (such as the Accountable Health Communities Model) would also not meet the proposed criteria for the APM scoring standard. CMS plans to include a list of “MIPS APMs” on their website.

For organizations that are participating in Medicare demonstrations or alternative payment models who are not sure whether they are in a MIPS APM or an Advanced APM, it is important to note that CMS has emphasized that the criteria for the identification of MIPS APMs are independent of the criteria for Advanced APM determinations. That means that a payment model that meets the definition of a MIPS APM may or may not also be an Advanced APM. As such, it would be possible that an APM meets all three proposed criteria to be a MIPS APM, but does not meet the Advanced APM criteria.

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
2 The 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


Further reading:
A new era for measure development: Clinical Quality Language is here!
Radiology & MIPS Reporting: Everything You Need to Know

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