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How Will MACRA Affect Your Medical Practice?

April 6, 2017

cms-MACRA.jpgAs you know, CMS issued final rules for MACRA last October, and while implementation is actually scheduled for January 2019, CMS will use performance data from 2017 to calculate payment adjustments. Unless your practice meets the low volume threshold of $30,000 or less in Medicare charges (or fewer than 100 Medicare patients), it is likely to be affected by the new MACRA framework. 

What payment tracks are available under MACRA?

There will be two primary tracks: Merit-based Incentive Payment System (MIPS) and Advanced Alternate Payment Model (AAPM). The vast majority of practices—roughly 80% to 90%—will fall under the MIPS track. 

Under MIPS, Meaningful Use, the Value-Based Payment Modifier, and the Physician Quality Reporting System have been consolidated into a single program CMS will use to score providers in order to calculate their payment adjustments. 

The adjustments are significant. Beginning in 2019, clinicians could see penalties of up to -4% and incentives as high as 9%. Over the course of a few years (by 2022), the penalties will increase to as much as -9% and the bonuses to as much as 27%. 

How will performance be scored?

Four categories will be measured: Quality, Cost, Improvement Activities, and Advancing Care Information. In 2019, the categories are weighted with Quality at 60%, Cost at 0%, Improvement Activities (IA) 15%, and Advancing Care Information (ACI) 25%. By 2021, the weights will shift to Quality and Cost at 30% each, while IA and ACI will remain the same. 

There are a few key differences from the old programs (PQRS, MU, etc.) and the new rules under MACRA. For example:

  • PQRS was a pay-for-reporting framework while MIPS is performance-based.
  • Part D costs will be considered under MIPS.
  • Meaningful Use activities will apply to all providers, not just Medicare doctors. 
  • EHR use is no longer an all-or-nothing metric; providers can earn partial credit. 

Improvement Activities are an entirely new metric under MIPS and focuses on activities such as care coordination, patient safety, and population management. There are 90 activities across nine broad categories, each is weighted differently. 

How will CMS use performance data to calculate payment adjustments?

Each clinician or group entity will be assigned a composite score of between 0 and 100 based on performance metrics. CMS will calculate a mean or median score for all MIPS participants and each provider/entity will be measured against that performance threshold. Those that exceed the threshold will receive incentive payments while those that fall below will be penalized. Adjustments are on a sliding scale, so the farther your score is from the threshold, the greater the adjustment. 

Note—In order to avoid an adjustment, your score must exactly match the threshold. Even a one point variation will result in an adjustment. 

High performing individuals and entities have an opportunity to earn additional bonuses. CMS is holding a $500 million pool (to be spread out over six years) which will be used to reward top performers. Practices that fall into the top quartile will receive a sliding scale bonus payment of between 0.5% up to 10% maximum. 

What are the reporting requirements for 2017?

Following a huge backlash against the original requirements released in October, CMS has modified the reporting requirements for 2017:

  • To avoid a penalty, you must report any single measurement under Quality, Clinical Improvement, or the ACI measures. 
  • To qualify for a small bonus, you must report a full 90-day period for at least two measurements as above. 
  • To qualify for the full bonus, including extra payments, you must report a full 90-day period for all required categories. 

This is a boon for smaller practices who can now avoid a penalty by simply reporting a single measurement this year. 

If you have questions about how MACRA will affect your revenue this year, contact us for a free consultation with our medical billing specialists. 

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