What is MACRA
What is MACRA: The Medicare Access and CHIP re-authorization Act (MACRA) came to be in 2015 through an effort to improve the way Medicare part B service providers are paid. Congress put MACRA in place and created the QPP (Quality Payment Program) in order to move to a value based payment system.
What is MACRA; how does it use the QPP:
Medicare pays for qualified medical providers’ services by using the quality payment program. As a result, the QPP was started in 2017. CMS stated that from 2017 until 2021 they will be flexible on data collection policies. This will give providers sufficient time to adjust to the program. There are 2 ways to adjust the payment amounts a provider receives with this system. The payments are based on both the quality and value of care provided to the medicare patients.
- The first payment method is referred to as MIPS or Merit-based Incentive Payment System. This pays providers who receive reimbursement through the fee-for-service method.
- The second method of payment is the Advanced APM or Advanced Alternative Payment Model. This method is used when a healthcare provider has a large portfolio of Advanced APMs. This is the case, when a provider’s portfolio includes risk-based accountable care organization models.
Who does the QPP apply to:
Any provider who bills Medicare Part B is considered part of the QPP system. Keep in mind every payment track has separate requirements in order to be eligible.
Starting in 2019, the CMS added to the types of clinicians who qualify to participate in MIPS. The list now includes physical therapists, occupational therapists, clinical psychologists, and registered dietitians/nutrition professionals. In the years 2017-2018 the list only included; certified registered nurse anesthetists, clinical nurse specialists, nurse practitioners, physicians, and physician assistants.
There are a number of requirement updates by the CMS for MIPS. In order to qualify in 2018, a healthcare provider had to treat a minimum of 200 Medicare beneficiaries. They also had to submit at least $90,000 in Medicare Part B claims. During the first year as a Medicare Part B provider, eligible clinicians do not have to participate in MIPS. CMS has added an eligibility threshold for providers who submit less than 200 Medicare covered professional service claims under the Physician Fee Schedule. For 2019, CMS will allow clinicians or groups who meet some of the requirements of these eligibility thresholds to opt into MIPS.
The Advanced APM track is open to additional types of providers beyond those eligible for MIPS. The APM includes, certified nurse-midwives, clinical social workers, qualified speech-language pathologists, and qualified audiologists. To qualify for the advanced APM track in 2019, providers must have at least half of their Medicare patients or 35% of their Medicare payments billed through an Advanced APM.
CMS has estimated that about 798,000 health care professionals in 2019 will be subject to MIPS. In addition, between 165,000 and 220,000 health care professionals will qualify for the Advanced APM track.
The MIPS and Advanced APM tracks, explained
The MIPS Track
Physicians’ pay in the MIPS track largely follows a traditional fee-for-service structure—but CMS adjusts eligible professionals’ pay based on how they “score” in four categories of metrics: promoting inter-operability, improvement activities, and quality. (MIPS consolidated parts of three previous federal programs: meaningful use, the Physician Quality Reporting System, and the Physician Value-based Payment Modifier.)
Based on providers’ performance on those metrics, CMS scores participants and assigns them a positive, neutral, or negative payment adjustment. For instance, eligible professionals who participate in MIPS in 2019 may be eligible for an estimated near 5% incentive; and for those that do not report a 7% reduction to their claims in 2021. Providers face a two year lag between their performance and payment adjustment. The MIPS payment adjustment applies to only Medicare Part B covered professional services.