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The proposed MACRA rules: a breakdown for providers

May 10, 2016

The proposed MACRA rules: a breakdown for providersMACRA.jpg

What is MACRA?

The Medicare Access and CHIP Reauthorization Act, passed by Congress in April, 2015, to put it simply, was intended to replace the Sustainable Growth Rate (SGR) Formula with new ways of reimbursing physicians for Medicare Part B health care. MACRA will reimburse participating doctors based on the quality of care, not volume, as with the current fee-for-service system. It’s important to note that the Act only applies to physicians, not hospitals, nor is Medicaid included.The new law also provides for funding for providers’ technical assistance, development and testing of quality measures, as it enables better data sharing as well as provisions for more objective third-party validation – in short, MACRA has the potential for creating major changes in both the delivery and reimbursement of health care.

What are MACRA’s new reimbursement models?

Merit Based Payment System (MIPS)

Physician Part B reimbursement will be based on the following four criteria:

  • Quality
  • Resource use
  • Clinical practice improvement
  • Meaningful Use of certified EHR technology

This path is expected to affect over 746,000 eligible providers for adjustments by 2019 however, reality will set in next year when CMS begins performance measurements in 2017. All physicians will start with MIPS for the first year, after which CMS will determine who meets criteria for moving on to the Alternative Payment Models track. The proposed rule extends the MU reporting period to a year.

Alternative Payment Models (APMs)

Qualified providers, including Accountable Care Organizations and Patient-Centered Homes, can become designated as Qualifying ARM Participants (QPs) and not subject to MIPS. They may also be eligible to participate in 5% lump-sum bonuses from 2019 through 2014.

Eligible Alternative Payment Models (e-APMs)

At the most advanced level, ‘eligible’ APMs will qualify for even higher performance-based reimbursement rates. 

The potential downside of MACRA:

There has been some skepticism leveled at the new changes, mostly from smaller practices with a high Medicare patient load that see themselves as being hit harder by the proposed rules. One concern is that while the rules are supposed to improve quality of care, reality will prove otherwise: the focus will be on data and metrics rather than the patients as small and solo practices struggle to meet the documentation requirements.

For example, a physician seeing a diabetic patient who is in otherwise good health and properly manages his or her condition may be more likely to be rewarded for better metrics. On the other hand, sicker patients who require more face-time and whose conditions are not expected to reach the goals set forth by MIPS may be adjusted negatively, possibly resulting in penalizing the treating physician.

Smaller practices need to make their opinions and suggestions heard during the open comment period between April and September, 2016; in November 2016 the final rules will be published for MACRA’s implementation.

Related Article: 6 Revenue Cycle Management Challenges Facing Providers Today

How a professional medical claims management company can help:

Due to time constraints  as well as the length of the document itself many providers haven’t heard much about MACRA or the new rules. While some may decide to opt out of Medicare entirely, this  hurts patients and severely impacts revenues of smaller Medicare-heavy practices.

If taking time to learn about and implement these new rules seems overwhelming, consider partnering with a professional claims management service, such as M-Scribe Technologies, LLC. As a leader in the medical claims management and documentation industry since 2003, M-Scribe offers practices of all sizes and specialties the latest in technology, coupled with the highest levels of training and experience to stay on top of the latest changes in government and industry regulations. Contact them today for a free consultation to learn how to be CMS-compliant while increasing productivity and revenues.


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