MACRA is full of acronyms and unusual-sounding programs.
But it actually reduces down the great number of quality measurement programs within Medicare and attempts to incentivize better care.
The Physician Quality Reporting System (PQRS), the Value Modifier Program (VMP) and the Medicare EHR Incentive Program all disappear.
This all starts really soon, with reporting beginning in 2017 and the first MIPS-based payments starting in 2019. To get your practice ready for these changes, here is a brief overview of MACRA‘s Merit-based Incentive Payment System (MIPS), the program most clinicians will report through, including many chiropractors accepting Medicare Part B.
Assigning doctors a score, MIPS determines whether they receive a Medicare incentive or a decrease in reimbursements under Medicare Part B. This score has four parts during the first year of MIPS. Each category has a set percentage of the total score for the first year, although this may change in future years. The four MIPS categories are:¹
- Quality: 50 percent of your score. You are allowed to choose six measures to report, out of more than 200 different measures. The majority of these measures are based on specialty, so chiropractors will be allowed to choose quality measures that fit the care they offer.
- Cost: 10 percent of your score. This category is entirely based on the claims you submit to Medicare, so no additional reporting is necessary for Medicare to score your cost.
- Clinical Practice Improvement: 15 percent of your score. More than 90 different measures are available to choose from based on specialty.
- Advancing Care Information: 25 percent of your score. This score depends on your use of EHR. As with other categories, you can choose measures to report that reflect your own use of EHR in your practice.
The cost category is the only one based strictly on Medicare participation, since the other categories include non-Medicare encounters and measure your overall performance. In other words, when you track and report these measures, you should include your non-Medicare patients and visits.¹
Based on how well you perform on these four categories, you may get an incentive from Medicare as high as 4 percent of your total Medicare reimbursement. If you fall short in your overall score, your reimbursements may be decreased by up to 4 percent. MIPS is required to be cost-neutral, so decreases in payments for some clinicians are used to pay for incentives paid to top performers.
Some doctors are exempted from MIPS. If your Medicare billing is less than or equal to $10,000 each year and you have fewer than or exactly 100 Medicare patients, if you are new to billing Medicare or if you participate in an Advanced Alternative Payment Model (APM), then you may not be required to participate in MIPS.
Initially, the vast majority of clinicians will report through MIPS. After the first year, some will become eligible for operating under the rules for APMs, which are different from MIPS. APMs are also eligible to receive a lump sum incentive payment from Medicare.²
Generally, these are Patient-Centered Medical Homes (PCMHs) and other multi-physician practices that take on a certain amount of financial risk based on gaps between their expected and actual expenditures. Medicare is incentivizing physicians to group their practices this way, with payment incentives for participants.¹
Doctors are not stuck in one program forever. Each year, if they meet the requirements, they can move between MIPS and APM participation.
Chiropractors, regardless of whether or not they accept Medicare, should carefully review the Centers for Medicare and Medicaid (CMS) guides and learn more about the upcoming quality measures. In time, some of these same measures may be adopted by private insurers.
Be prepared. You may actually qualify for better Medicare reimbursements if you are ready for MACRA.
Remember, although this article uses information from CMS, it is subject to change. Be sure to verify any information you plan to use for your own practice.
¹CMS, “Quality Payment Program Fact Sheet.” CMS.gov. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf. Published: April 2016. Accessed: July 2016.
²CMS, “Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA.” CMS.gov. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed: July 2016.