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MACRA/Quality Payment Program

The Medicare Access and Chip Reauthorization Act of 2015 (MACRA) repealed the flawed sustainable growth rate formula and set in motion predictable Medicare Part B payment updates and shifts practices toward value-based reimbursement through the Quality Payment Program (QPP). Under the QPP, practices may be required to participate in the Merit-based Incentive Payment System (MIPS), a new, all-encompassing federal quality reporting program that potentially adjusts Medicare payments based on performance on quality, cost, EHR, and improvement activity metrics. Alternatively, practices may participate in an advanced alternative payment model (APM), which may exempt them from MIPS and qualify them for a 5% lump sum bonus.

NEW

  • View MGMA's member-benefit "2018 Medicare Outlook" on-demand webinar for an in-depth look at 2018 MIPS and APM policy requirements
  • Access MGMA’s member-exclusive analysis of the final 2018 Medicare physician fee schedule and the 2018 MIPS/APM rules

 

Sign up for MGMA's MACRA Member Community for access to questions and discussion on MIPS and APMs 

Want to learn more about APMs? Check out MGMA's APMs Resource Center

Subscribe to MGMA's Washington Connection for the latest news on the future of the QPP and other pressing industry topics

Check out MGMA's library of member-exclusive MIPS resources including a comparison chart of 2017 and 2018 requirements and more

MIPS in 2018: The basics

2018 is the second performance year of MIPS. Eligible clinicians will be subject to upward, neutral or downward payment adjustments in 2020 based on their performance this year in four performance categories: quality, cost, advancing care information (ACI) and improvement activities. Each MIPS performance category is weighted to contribute to your final MIPS score, which is calculated out of 100 points. Scoring 15 points or higher will avoid a 5% penalty, while higher scores may qualify for a modest bonus.

Continue reading for steps to ensure your practice is MIPS compliant in 2018.

Expanding Item - View More Step 1: Determine MIPS eligibility

In 2018, the following types of clinicians generally must participate in MIPS to avoid a penalty in 2020: Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists.

Clinicians may be deemed ineligible if one of the following applies:

  • Newly enrolled in Medicare (i.e., never billed Medicare in a previous year)
  • Fall below the MIPS low-volume threshold (i.e., bill $90,000 or less in Medicare allowed charges or treat 200 or fewer Medicare beneficiaries)
  • Significantly participating in an Advanced APM
  • Partially participating in an Advanced APM and opt out of MIPS

Expanding Item - View More Step 2: Set your 2018 MIPS goal


While MGMA strongly encourages practices to avoid a MIPS penalty, group practices should weight the costs and benefits of robust participation in MIPS. Practice leaders should consider both the short-term (e.g., cost of purchasing a new registry, etc.) and long-term (e.g., increasing MIPS penalties and reporting requirements over time, etc.) implications when setting a MIPS goal. 

Expanding Item - View More Step 3: Establish a reporting strategy

Clinicians may report and be evaluated individually, collectively under one Tax Identification Number (TIN), or as part of a "virtual group," comprised of multiple TINs.

Looking to avoid a penalty?

Clinicians and group practices must earn at least 15 out of 100 points in 2018 to avoid a Medicare payment cut of up to 5% in 2020. This is an increase from the 2017 threshold of three points but can be achieved by satisfying the requirements of one MIPS category or subparts of multiple MIPS categories. For instance, ECs and group practices that participate fully in the improvement activities category will receive 15 points and avoid a penalty.

Looking to qualify for a bonus?

In 2018, MIPS scores are based on performance in four categories, each with its own reporting and scoring metrics and each accounting for a set proportion of the total MIPS score of 100 points. MIPs is scored on a “sliding scale,” which means you may satisfy as many or as few requirements from each of the categories, but satisfying more MIPS criteria and   performing well on individual metrics puts you in the best position to maximize your score.  

For more information about MIPS, click here.

Expanding Item - View More Step 4: Review and submit data

At year-end, practices should work with their vendors to ensure MIPS data is properly reported. Practices have important decisions to make at this time, including which data to report, whether to report data individually or as a group, and which measures to report. In general, the data submission deadline is Mar. 31 after the performance year. In other words, 2017 data is due to the Centers for Medicare & Medicaid Services by Mar. 31 2018.

MGMA Advocacy

  • MGMA calls for immediate release of 2018 MIPS eligibility information
  • MGMA to CMS: Support patients over paperwork and the group practice model in 2018 MIPS and improve the Other Payer Advanced APM option
  • MGMA comments in response to CMS' request for information on CMMI's new direction
  • MGMA submitted comments to CMS regarding its testing of eight episode-based cost measures and related feedback reports
  • MGMA joins other medical associations to urge Congress to ensure CMS has implementation flexibility with the Quality Payment Program (QPP)
  • MGMA to CMS: Reduce reporting burden in MIPS, expand APM opportunities
  • MGMA joins several provider organizations urging CMS to include group practices in APMs with Medicare Advantage plans in the APM track of MACRA

 

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