If you are like many providers, you were probably just getting used to the CMS programs and Meaningful Use when they passed their latest payment reform policy—MACRA. Now, you may find yourself confused and concerned with how this new program will affect your practice. If you currently enlist the services of a 3rd party billing company, they should be able to clear the fog of confusion and ease the burden of this stressful change in CMS reimbursement policy.

Our philosophy at MEREM Healthcare Solutions, as a comprehensive revenue cycle management company, is to help our clients by allowing them to focus on what they do best—serving their patients—by absorbing the stress that comes with payment reform and the other complexities of the reimbursement cycle.

Below we have answered some of the most common questions we are hearing from our providers. Giving you a brief and concise explanation of what the program is, how it will impact your practice, and what you need to do to prepare and participate.

What is MACRA?

MACRA is the newest Medicare Payment Reform policy that aims to emphasize healthcare quality by ending the Sustainable Growth Rate formula (a cost/inflation-based formula used to determine annual fee schedule increases) and replacing it with an option between 2 Quality Payment Program tracks: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Alternative Payment Models).

This article will be focused around MIPS, as it will be the track chosen by the majority of the physicians we serve. In short, MACRA changes how CMS determines your annual payment adjustment.

What is MIPS?

In many ways, MIPS is aiming to simplify the CMS programs you are already familiar with: PQRS, MU, and Value-Based Modifier. MIPS is made up of 4 components:

  1. Quality– Replaces PQRS
  2. Improvement Activities– a new reporting category
  3. Advancing Care Information– Replaces Meaningful Use
  4. Cost– Replaces the Value-Based Modifier

So you can see that, if you have already been participating in these programs, you are ahead of the learning curve.

How will MACRA/MIPS affect my Medicare Payments?

While MIPS reporting begins in 2017, the adjustments will not start until 2019. Through 2019, CMS will increase the fee schedule .5% annually. Beginning in 2019, you will receive a +/- adjustment based on your level of participation and performance with the MIPS program. To clarify, 2017 reporting = 2019 adjustment, 2018 reporting = 2020 adjustment, etc.

The maximum +/- adjustment for 2019 is 4%, 2020 is 5%, 2021 is 7%, and 2022+ is 9%. MACRA allows an additional $500M to be awarded between “Exceptional Performers.” Up to 3x adjustment (though unlikely that much) is allowed to balance the downward adjustments (the program is budget-neutral).

How is my MIPS adjustment determined?

The first part is your Composite Performance Score (CPS) for MIPS

  • Quality — 50% of your CPS, scored on 6 measures you select (vs. 9 with PQRS).
  • Clinical Improvement Activities — 15% of your CPS, 90+ activities to choose from. Need at least 1 and up to 4 for full credit.
  • Advancing Care Information — 25% of your CPS, report on the 6 measures: You get 50 points for reporting all 6, an additional 20 points for performance are available for each measure 2-5. Max score = 100, so a max of 25 points on your CPS.
    1. Protect Patient Health Information (Y/N)
    2. E-prescribing (%)
    3. Patient Electronic Access (%)
    4. Coordination of Care through Patient Engagement (%)
    5. Health Information Exchange (%)
    6. and Public Health and Clinical Data Registry Reporting (Y/N)
  • Cost (Resource Use) — 10% of your CPS, CMS will calculate based on submitted claims, so nothing to report.

The second part is your CPS vs MIPS performance threshold.

  • CPS = MIPS performance threshold → 0% adjustment
  • CPS > MIPS performance threshold → 0 – 12% + adjustment based on degree threshold is exceeded. *Bonus of up to 10% for “exceptional performance”
  • CPS < MIPS performance threshold → negative adjustment up to -4% for 2017 data (2019 adjustment year)

A key take away here is that, since the program is designed to be budget-neutral, the MIPS performance threshold and the % adjustment for your score are determined by analyzing the CPS of ALL eligible clinicians. That means there is no way for you to know “the minimum of what you can do” to earn a certain adjustment. The recommendation, therefore, is to try and maximize your score for the best possible positive adjustment.

How do I report to MACRA for my MIPS measures?

  • Quality — Same as with PQRS, data submission method depends on the measures you select. Visit http://qpp.cms.gov to look at specific measures.
  • Clinical Improvement Activities — Also dependent on the activities you choose, but can include attestation, Qualified Clinical Data Registry (QCDR), Qualified Registry, or your EMR.
  • Advancing Care Information — Similar to MU, you will use any or a combination of attestation, QCDR, Qualified Registry, and your EMR to collect and submit the data.
  • Cost (Resource Use) — CMS uses your claim data, so no additional reporting is required.

What do I need to do right now to prepare?

The reporting for 2017 begins January 1st. The minimum reporting period is 90 days to receive a neutral to small positive payment adjustment for 2019, but submitting a full year of data is required to reach the higher adjustments. That being said, here are the steps you should begin to follow now:

  1. Visit http://qpp.cms.gov and choose the 6 quality performance measures you intend to report. The website will explain the requirements in more detail but know that 1 must be an outcome measure.
  2. You will also be able to explore the measures for Advancing Care Information and Clinical Improvement Activities.
  3. When you select your measures, you will be able to download a CSV file for your records. ***PLEASE NOTE*** when you “select” these measures, you are not submitting anything to CMS and are able to change the measures if you choose. This website is just informative.
  4. Contact your billing company. Let them know the measures you are planning to report and they will assist you from there.

What should my billing company be doing for me?

Once you inform them of your intention to participate and the measures you are planning to report, your billing company should take it from there. They should:

  • Coordinate with your EMR vendor to verify how/what data they are able to capture and submit.
  • Inform you on how you can document quality measures that can be submitted on claims and ensure their coding staff is submitting those codes.
  • Help you along the attestation process, if necessary.
  • Coordinate with any Qualified Registries with which you participate.
  • Keep you informed of any changes to the MACRA program and its requirements.

Let MEREM Healthcare Solutions keep you “ahead of the curve”

I hope that you will now see MACRA/MIPS as an opportunity rather than a looming threat. CMS is allowing you as a physician to “control the destiny” of your future Medicare payment increases; and, with a knowledgeable and client-focused revenue-cycle management company to assist you, all you have to do to maximize the potential benefit of the program is continue to provide quality care to the patients you serve.

However, if you find yourself without the assistance and support you deserve from your billing company; or, if you currently handle billing and coding in-house, I encourage you to contact us at MEREM Health. We would be happy to discuss our services, assist you in evaluating the performance of your current billing and coding operations, and help you to build a revenue cycle solution that fits the needs of your practice.

MEREM Healthcare Solutions

205-329-7519

Request Information