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MACRA Final Rule Explained – Key Points

October 26, 2016

MACRA Final Rule ExplainedLast week, CMS released its final rule for MACRA, the game-changing Medicare reimbursement system. Considering the reporting period for the new payment regime begins in 2017, it’s not too soon to take a look at some of the provisions in the final rule and how they may impact your practice. 

Who is affected by MACRA?

All providers, including mid-level practitioners, who have at least 100 Medicare patients or who bill Medicare at least $30,000 per year, will qualify for MACRA. If you are new to Medicare in 2017, you will not have to report next year. You can begin reporting between January 1st and October 2nd, but all reports are due by March 31, 2018. The first payment adjustments will begin in January 2019. 

What participation options are available?

There are two tracks under MACRA: The Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). MIPS is designed for providers under Medicare’s fee for service system while APM is for organizations who are under a risk-based payment model. About 90% of providers will be on the MIPS track. 

What does the final rule say about MIPS?

MIPS replaces (and ultimately retires) Meaningful Use, the Value-Based Payment Modifier, and the Physician Quality Reporting System (PQRS). Payment adjustments of between -4% and +4% will be based on four measures: Quality, Resource Use, Clinical Practice Improvement Activities (CPIA), and Advancing Care Information (ACI). It will raise to 9% by 2022. 

The ramp-up for 2017 looks like this:

  • No participation and an automatic 4% payment reduction. 
  • Submit minimal data for no adjustment to payment rates. 
  • Submit data from a 90-day reporting period; small positive or negative adjustment based on data. 
  • Report a full year of data for a more substantial payment adjustment. 

If your practice is on the MIPS track, your payment calculation will be based on RVUs, the Medicare fee schedule conversion factor, and the MIPS adjustment factor. 

How does the rule affect advanced APMs?

There is a difference between an APM and an advanced APM under the rule. To qualify as an advanced APM, a practice must use a certified EHR, use MIPS-type quality measures for payment, and assume more than “nominal” risk, which is defined as:

  • A loss trigger of 4% or less. 
  • Loss sharing of at least 30%. 
  • Maximum loss of 4% or greater. 

Clinicians who qualify for the APM payment track do so as part of an organization; there is no individual pathway for individual clinicians. APMs qualify for a 5% bonus each year between 2019 and 2024. The approved models for advanced APMs include:

  • Comprehensive ESRD care model. 
  • Next generation ACO. 
  • Comprehensive Primary Care Plus model (CPC+).
  • Medicare Shared Savings Program (Track 1 and Track 2).

How can small practices participate in MACRA?

Solo providers and small practices can join “virtual” groups to submit MIPS data collectively if they do not meet the minimum volume for participation. The rule allocates $20 million for education and training for practices of fewer than 15 physicians and those in underserved areas. 

How does the rule affect non patient-facing physicians?

The new rule created a definition for non patient-facing physicians which states that a physician or group that bills fewer than 25 patient-facing encounters in a reporting period can qualify to participate as a non patient-facing entity. 

Non patient-facing entities have different reporting requirements under MIPS, which include eliminating the “cross cutting measure” from the six required measures and allowing these entities to report through a QCDR that accommodates non-MIPS measures. 

Where can I find more information about the MACRA final rule?

There is a new website for affected practices at QPP.CMS.GOV. CMS is also rolling out a full service center with email and phone response capabilities for those with additional questions. 

If you are concerned about the new MACRA requirements and how they affect your practice, contact the billing specialists at M-Scribe today for a free consultation.


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