MACRA & MIPS – Coming our way!

MACRA & MIPS – Coming our way!

We want to be sure our clients are kept in the loop on upcoming Medicare changes and payment models. The new acronyms to know are MACRA and MIPS…

 MACRA (Medicare Access and CHIP Reauthorization Act ) is the umbrella piece of legislation passed in 2015 that is aimed at shifting healthcare reimbursement from strictly fee-for-service quantity to a value-based system to pay for quality. MACRA set rules to eliminate the SGR model and ruled that SSN need to be removed from Medicare ID’s by April 2019.  But one of the most impactful components of MACRA is MIPS (Merit-based Incentive Performance System).

MIPS takes the place of the three former bonus/penalty concepts of PQRS, the Value-based Payment Modifier, and the EHR incentive program. According to the government, MIPS is an attempt to better analyze and reward Quality, Resource Use (cost), Advancing Care Information (EHR use), and Clinical practice improvement activities  (patient engagement and safety). Under the MIPS system, providers will encounter either penalties or bonuses each year —- starting in 2019. While providers will not see their payments dinged or increased until 2019, it is important to realize that those penalties are based on what happens starting 01/01/2017. (The penalty/bonus will always be based on encounters from 2 years prior). The penalty/bonus starts at 4% for 2019 payments, then 5% for 2020, 7% for 2021, and 9% for 2022.

What determines your penalty or bonus? Rather than defining black-and-white benchmarks, MIPS compares each provider or group data against other providers. It is like being graded on a curve. The money to withhold/reward is budget-neutral —- meaning, the penalties from those who do poorly are used to pay the bonuses for the providers that do well under this system. The measurements for doing well vs. poorly are based on the categories mentioned above — Quality, Resource Use (cost), Advancing Care Information (EHR use), and Clinical practice improvement activities  (patient engagement and safety). The primary MIPS Data Submission Options are through Qualified Clinical Data Registry (QCDR), EHR Vendors, and/or Claims data. The bonuses/payments apply to MEDICARE payments. Medicare excludes from MIPS those that have equal to or less than 100 Medicare patients or bill less than or equal to $10,000 a year to Medicare. No other payers have committed to using this system yet, though industry experts suggest that the other payers will implement similar quality-cost value-based payment models in the next several years. Industry experts also expect this legislation to go into place regardless of the outcome of the presidential election.

We are waiting right now for CMS to give a final ruling (expected on or by Nov 1 2016) that gives specifics on what providers need to do starting 01/01/17 to avoid the penalty or earn the bonus. CMS has hinted that they are going to use the first year as a type of grace period with minimal reporting demands for providers that simply want to avoid the penalty and dip their toes into the new model (see HDM will keep you posted as soon as we learn more from that final ruling. In the meantime, if you would like to discuss your practice’s specific concerns, please don’t hesitate to reach out to us!

 Additional Resources:

Steps You Can Take Now to Prepare:

 MIPS graphic Overview from CMS: