On Friday October 14th CMS released the final rule of MACRA. Since many providers and staff that we encounter still have not even heard of MACRA despite being bombarded with emails and newsletters with information, we will start at the beginning.
MACRA is The Medicare Access and CHIP Re-Authorization Act which was signed into law in 2015 and is slated to be implemented in 2019. Even though it will not be implemented until 2019 it will be based on performance data from 2017. Many providers seem to be ignoring the information on MACRA. Maybe because they see the year 2019 and figure they still have time, or maybe because it is just too darn confusing to figure out. In either case, ignoring MACRA can be a costly mistake.
Basically MACRA takes the Meaningful Use (MU) Electronic Health Record Incentive Program, Physician Quality Reporting System (PQRS), and the Value-Based Modifier (VBM) program and combines them all into one Merit-Based Incentive Payment System (MIPS) program.
What does that mean to providers or Eligible Professionals (EPs)? Well it means that EPs will be assigned a MIPS composite performance score. This score will be calculated on a scale from 0 to 100 and will significantly influence their Medicare reimbursements. In 2019 a provider’s payments may be anywhere from -4% to +4% depending on their MIPS composite performance score.
The MIPS composite performance score will be divided into the following components:
60% Quality (PQRS) – If providers are not reporting PQRS then they are could have a score of 40 or below right off the bat.
25% Advancing Care Information – This was previously known as Meaningful Use or EMR. If providers are not demonstrating Meaningful Use then they could lose 25 points of their MIPS composite performance score.
15% Improvement Activates – EPs will be able to choose from a list of activities that best fit their practice. At least one activity must be selected. The activities are categorized as “medium” or “high” weight. Full credit for this portion of MIPS is 60 points. A high weight category earns 20 points and a medium earns 10. One way an EP can earn 60 points would be to participate in three high weight activities from the list.
MACRA replaced the old Sustainable Growth Rate (SGR) method of determining fee schedule amounts for providers. Providers will now have fee schedules that will be determined by their MIPS composite performance score. So it is possible that providers in the same physical location can have completely different reimbursement rates. This is not simply a 1.5% or 2% penalty. This will determine the fee schedule and may result in providers receiving up to -9% by the year 2022.
The problem is that the score will be based on data from two years prior so the provider will have to deal with the lower fee schedule for up to two years in order to rectify the situation. Providers need to understand that the claims that they submit and the actions (or lack of action) they take beginning January 1, 2017 will affect their Medicare reimbursement in 2019.
If an individual EP works for more than one group, the performance score is a weighted average. If the individual EP changes groups, the performance score is based on the data from the previous period. So for example, if an EP works for Middleville Health Clinic for the entire year of 2017, but then switches to Johnstown Medical in 2018, their performance score for payments in 2019 will be based on their reported data from Middleville Health Clinic in 2017.
If an EP is newly enrolled, or they are below the low-volume threshold of $10,000 for the reporting year, then they will have no MIPS score and will be considered exempt for that year.
If an EP has Medicare billing charges less than or equal to $10,000 AND provides care for 100 or fewer Medicare patients in one year they are not subject to MIPS.