MIPS & MACRA

MACRA Quality Payment Program (QPP)

By law, (MACRA) Medicare Access and CHIP Reauthorization Act of 2015 required the Centers for Medicare & Medicaid Services (CMS) to establish value-based healthcare business models that link an ever-increasing portion of physician payments to service-value rather than service-volume.

These incentive-based business models, collectively referred to as the Quality Payment Program (QPP), provide two participation tracks for eligible clinicians—the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)—both of which involve levels of financial rewards and risks.

With MACRA, physicians have to choose the best way one of two paths to deliver quality care and participate in the program based on their practice size, specialty, location, or patient population paths.

They can go down the Merit-Based Incentive Payment System (MIPS) path, which are the reporting requirements that will generate these performance scores or they can focus on Advanced Payment Models, which avoids the reporting requirements because physicians are taking a direct risk on the total cost of care.

MIPS in healthcare doesn’t leave you with many alternatives except for Alternative Advanced Payment Models (APMs). Therefore, clinicians, once they are eligible, have to go through MIPS reporting.

MIPS

The Merit-based Incentive Payment System is one of two tracks under the Quality Payment Program, which moves Medicare Part B providers to a performance-based payment system.

The four performance categories included in MIPS are:

• QUALITY
• ADVANCING CARE INFORMATION
• IMPROVEMENT ACTIVITIES
• COST

HOW DO I KNOW IF I AM ELIGIBLE FOR MIPS?

Eligible Clinician Types:

• Physicians.
• Physician Assistants
• Nurse Practitioners

The Low-Volume Threshold:

• Bill Medicare an amount of $90,000 or more
• Provide care to 200 or more Medicare patients
• Provide 200 or more cover professional services to Medicare patients.

Other Possible Exemptions

• Newly Enrolled in Medicare: If a clinician enrolls in Medicare in the middle of a performance year, they do not have to participate in MIPS reporting that year.
• Advanced APM Participation: If an eligible clinician is a part of an Advanced APM, then they are exempt from MIPS

If you don’t meet one of the above requirements, consider yourself excluded from MIPS in 2020.

APM’s Advanced Payment Method

The APMs track reimburses Medicare providers based on value of services rather than service volume. Providers meeting the criteria for this track cannot move to the MIPS track. Physicians receiving a significant portion of their payments through eligible APMs can be exempt from MIPS—and they receive a lump sum payment of 5 percent of covered services.

The regulations provided more guidance on this track. Criteria include:

• The advanced APM must require use of certified EHR technology.
• Payment must be based on quality measures.
• There also needs to be financial risk or a medical home that meets certain criteria.

Generally, most providers will not meet the criteria for this track. There are some organizations that are automatically qualified.