In order to be able to talk intelligently with your physician clients about the product and service needs of their practices, it will be beneficial to understand their reimbursement issues under the new Medicare Quality Payment Program. So here is a quick summary.
1 - What is MACRA anyway? - MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015 which replaces the Sustainable Growth Rate (SGR) model for physician reimbursement on the Medicare physician fee schedule (PFS). As you may recall the SGR was plagued with issues which required the infamous “Doc Fix” legislation every January for many years to keep from reducing the rates at which physicians would be paid for services to Medicare patients that year.
2 - What is the Quality Payment Program? - The Quality Payment Program (QPP) is the methodology under MACRA by which eligible clinicians (ECs) will be reimbursed. The QPP is planned to emphasize the quality of care provided as opposed to the quantity of services rendered. The idea is to reimburse in a way that promotes value over volume.
3 - How will this work? - QPP includes two tracks —
- Merit-based Incentive Payment System (MIPS), and the
- Advanced Alternative Payment Models (APMs)
These two tracks will contain opportunities for either a positive adjustment (incentive) to the reimbursement rate for individual ECs, or groups, that do well, and also a negative adjustment (penalty) for those that do not. It is designed to be financially neutral with the idea that the positive and negative adjustments will offset each other.
4 - When does this start? - It already started as of January 1. This year, 2017, is the base year on which the reimbursement rate for 2019 will be figured. The reimbursement rate for each year will be figured on the performance during the year two years previous.
5 - Who does this program affect? - The MACRA QPP will affect all eligible clinicians who
- Began seeing and billing patients prior to January 1, 2017, and
- Are paid more than $30,000 a year in Medicare claims, and
- See more than 100 Medicare patients a year.
If any one of these three requirements are not met, the clinician will not be eligible to participate in the program for 2017.
6 - Who is an Eligible Clinician? - To be an EC the healthcare professional must be a:
- Physician assistant
- Nurse practitioner
- Clinical nurse specialist
- Certified registered nurse anesthetist
7 - How does an EC participate in the program? - There is one level of non-participation, plus four levels of actual participation in 2017 as follows:
- O - No participation -> a negative reimbursement adjustment of up to 4% for 2019.
- 1 - Minimal MIPS participation (submit something) -> zero adjustment, avoiding the penalty.
- 2 - Partial year MIPS participation (submit at least 90 days of data) -> potential positive adjustment.
- 3 - Full year MIPS participation (submit data for entire year beginning January 1 through December 31,2017) -> potential for 3-4% rate increase.
- 4 - Participate in Advanced Alternative Payment Model -> 4-5% rate increase
8 - What are the merit incentives of the MIPS program? - The MIPS pathway, which will be the bulk of the QPP participants in 2017, consists of four categories of data reporting which will replace three current Medicare reporting programs.
New Category Replaces Current Program
Cost Value-Based Payment Modifier
Quality Physician Quality Reporting System (PQRS)
Advancing Care Information EHR Incentive Program (Meaningful Use)
Improvement Activities No current program
9 - How is the Incentive Calculated? - For MIPS the payment will be based on the EC’s performance in each of the new categories and w as follows:
- Cost = 0% The Cost category will not be factored in for 2017
- Quality = 60% A heavy emphasis on Quality measures reported for 2017
- Care Information = 25% Continued emphasis on Meaningful Use of EHRs
- Improvement = 15% The new category to address improvement activities
In addition, you will need to bear in mind that all Medicare payment recipients will be looking at how you can help them comply with the Triple Aim for healthcare reimbursements of:
- Reducing Costs
- Improving the Quality of Care, and
- Enhancing the Patient Experience.
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