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Reimbursement and Practice Management


MACRA outlined a new model for Medicare payment, featuring two tracks. The first is to participate in an Advanced Alternative Payment Model (APM), allowing an automatic boost in Medicare reimbursement by five percent. The second track is the Merit-based Incentive Payment System (MIPS), the pathway for those bound by MACRA, but don’t participate in an Advanced APM. Participants may be eligible for a boost in reimbursement or the opposite, a downward payment adjustments because of the failure to successfully participate.

This article will provide information on the MIPS key requirements within the categories of quality, cost, advancing care information and improvement activities.

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Note: The information is accurate at the time of the writing of this article, however, the government often changes program requirements. Therefore, we suggest consulting current regulations to ensure successful participation. 

The Medicare Access to Care and CHIP Reauthorization Act (MACRA) offers two pathways to participate in the new Medicare payment model: participating in an Advanced Alternative Payment Model (APM) or the Merit-based Incentive Performance System (MIPS). Most eligible clinicians will participate in the new structure through MIPS.

Four categories define MIPS, each of which has a set of required criteria:

  • Quality, requiring up to six quality measures (less, if six are not clinically relevant), each of which is worth a maximum of 10 points; the measures can be reported via claims, registry, electronic health record (EHR) or QCDR (Qualified Clinical Data Registry). Scoring is based on performance, with your data being assessed based on comparison to measure-specific benchmarks. The scores are divided into deciles, with three points per measure offered simply for reporting the data in 2017. A perfect score represents 60 points, noting that CMS has pledged to take the highest scores if you report more than six.
  • Cost (aka Resource Use), eliminated for 2017, since CMS is working on the reporting elements of this category, including the methodology for assigning costs.
  • Advancing Care Information (ACI), requiring four or five so-called base measures, depending on the certification year of your electronic health record (EHR) system, with more than a dozen additional measures available to report with only a portion of them needed to reach a perfect score of 100. Although there is a new name, these criteria represent the former "Meaningful Use" measures, with a total of 155 points available.
  • Improvement Activities, a new category offering a list of 92 activities from which to choose. While the activities must be performed for at least 90 days, only a handful are required. Activities are assigned weights, with medium-weighted activities being worth 10 points and high-weighted activities worth 20. Opportunities include patient coaching, referral management, care plans, care coordination training, group visits, and telehealth. Forty points are needed for the maximum score, although there are exceptions (e.g., half of the points are waived for clinicians practicing in a Health Professional Shortage Area [HPSA]).

Because the Cost category is eliminated for the first performance year (2017), Medicare reimbursement is tied to the remaining three: Quality, ACI, and Improvement Activities. Those three categories contribute, respectively, 60%, 25%, and 15%, to formulate your composite performance score. The score determines your Medicare adjustment in 2019. The program begins in 2017, with MIPS reporting required by March 31, 2018. If you have been participating in the government's incentive programs to date, this new era will likely be an easy transition. For those of you who haven't, however, prepare to get up to speed — and quickly.

Pearl: Verify Eligibility

In 2017, participation under the new Medicare reimbursement model is required by all eligible clinicians, who will otherwise experience a four percent cut to all Medicare payments in 2019. Eligibility, however, is limited to approximately two-thirds of physicians and advanced practice providers, per the Centers for Medicare & Medicaid Services (CMS). Why? Clinicians who bill less than $30,000 in total Medicare Part B allowed charges or see less than 100 Medicare beneficiaries are not eligible, nor are those who have been enrolled with Medicare for less than a year. Meet any one of these criteria, and don’t need to worry about the new Medicare program titled the Merit-based Incentive Payment System (MIPS). CMS has posted a lookup tool; searchable by National Provider Identifier (NPI), use this resource to determine your MIPS eligibility.

Pearl: MIPS Exclusions

Physicians and other eligible clinicians who bill less than $30,000 in total allowed Medicare Part B charges are not required to participate in the Merit-based Incentive Payment System (MIPS). To understand this exclusion, it's important to recognize that Medicare Part B is limited to "traditional" Medicare plans; it does not include Medicare Advantage plans, which represent Medicare Part C. Furthermore, total allowed charges are defined by Medicare’s allowance for each service. (Your allowance may vary slightly, because Medicare has an allowance schedule based on geography.) Thus, the $30,000 represents the sum of the allowances, not your practice's gross charges or the payments associated with the services you render to Medicare patients.

Pearl: Quality Measures

Under the Merit-based Incentive Payment System, quality measures will be judged against measure-specific benchmarks. Depending on which measure you choose to report — up to six are required, with less only if there are none that are clinically appropriate — you will be assessed against other specialties. If, for example, you choose the measure, "Patient-Centered Surgical Risk Assessment Communication," all surgical specialties will be reporting. In sum, you'll be assessed against the measure, not just your specialty. The benchmarks, published in December 2016, just days before the start of the initial performance year of the MIPS, vary by reporting mechanism. The reason? The scope of patients depends on how you report. Claims-based reporting, for example, is limited to Medicare patients, while EHR-based reporting requires reporting on all patients, regardless of payer.

Pearl: Advanced Practice Providers

Your advanced practice providers are eligible clinicians under the Merit-based Incentive Payment System. They, however, are not required to participate in Advancing Care Information (ACI, the new name for Meaningful Use) in 2017. However, make note of the fact that they won't be scored at 100% for this category. Instead, Quality and Improvement Activities will be reweighted to 80% and 20% of their composite performance score. Therefore, you may wish to have them participate, particularly if the rest of the practice is complying successfully. Because the Quality category is, arguably, the most difficult category to gain a perfect score, moving forward with ACI may be the best method of mitigating the risk associated with declining reimbursement.

Pearl: Individual or Group Reporting

Eligible clinicians can report as individuals — or as a group — under the Merit-based Incentive Payment System (MIPS). Of course, if some of your clinicians are exempt, you may wish to report as individuals for the remaining ones. If you report as a group, you must include everyone in your practice's TIN (tax identification number), even if they might otherwise be individually exempt. Furthermore, group reporting must be done across all four MIPS categories: Quality, Cost, Advancing Care Information and Improvement Activities. (The Cost category is eliminated in 2017.)

United States