Healthcare Advisor: MACRA – Participate or Not Participate for Calendar Year 2017

March 13, 2017

There once was a provider of Medicare who in 2017 had a great scare. What is this QPP, APM and MIPS and this MACRA on everyone’s lips? Now providers are worried about being too slow. Here is some information for providers to know.

MACRA is the Medicare Access and CHIP Reauthorization Act of 2015. MACRA is not part of the Affordable Care Act (i.e. ACA or Obamacare), so do not wait on a government repeal to reverse MACRA mandates. MACRA is the “doc fix” bill that repealed the 1997 Sustainable Growth Rate (“SGR”) methodology Congress used to control Medicare spending on provider services. The SGR method was used to annually update the Medicare Physician Fee Schedule (“MPFS”). Each year Congress would appropriate more money so a cut would not take place, and providers were uncertain if Medicare would be funded at the beginning of each year. If MACRA had not been enacted in 2015, Medicare payments may have been cut by 21% in 2015. MACRA replaced the old Medicare Part B SGR with a new value-based reimbursement system, the Quality Payment Program (QPP).

If you do nothing, your Medicare payments will be reduced 4% in 2019. Read more to understand how to avoid the penalty.

First, it is not too late to make an informed decision regarding participation in MACRA. The first performance period for MACRA opened January 1, 2017, and closes December 31, 2017. If you, the provider, are not ready to submit data for participation beginning January 1, there are other options. You need to be prepared to decide to participate or not to participate for the performance year 2017, and your participation in 2017 determines your payment adjustment for 2019 Medicare payments.

Avoid being uninformed because it is easier to ignore MACRA. Make an informed decision to participate or not to participate based on how it will affect your practice in the future.

Second, identify if you meet the requirements to be scored under QPP. If you bill more than $30,000 Medicare Part B charges and provide care to more than 100 Medicare Part B patients, the QPP requirement has been met and you will be scored under the QPP.

Avoid ignoring the Medicare QPP website. Visit www.qpp.cms.gov to review if you, the eligible clinician and provider, meet any exemptions for the QPP.

The current year, 2017, is the transition year for participating in the QPP. Eligible clinicians may choose two tracks for participation, Merit-based Incentive Payment Systems (“MIPS”) and Advanced Alternative Payment Models (“APMs”). Medicare anticipates most Eligible Clinicians will be participating under the MIPS track for the transition year. Under the MIPS track, you may transition into the 2017 QPP performance year at your own pace, and you have four participation options.

Third, take advantage of the transitional year to participate because the performance year 2017 is not a pass. It is an opportunity for you to be educated and make informed decisions on how to transition into being acknowledged and reimbursed for the quality of patient care you provide and to avoid a negative payment adjustment.

Avoid not reviewing what your practice has or has not submitted in prior years. To determine your readiness, how to participate or whether to participate at all, find out answers to questions such as:

  1. Have Physician Quality Reporting System (“PQRS”) measures been submitted?
  2. Did you participate in electronic health record (“EHR”) incentives or meaningful use (“MU”)?
  3. Have you accessed the Quality and Resource Use Reports (“QRUR”) feedback reports to review how you compare to peers?
  4. Have you received a penalty letter for PQRS and MU? Was there a total sum of combined penalties?

A prior Elliott Davis Decosimo article found at http://www.elliottdavis.com/articles/healthcare-alert-macra-me discusses the four options for MIPS participation, the MIPS performance categories and weights and what other questions to consider when deciding how to participate in the QPP.

Consider this MIPS Scoring Overview table illustrating the payment adjustments for the 2019 Medicare payments through the QPP according to how an Eligible Clinician participates:

MIPS Payment Adjustment Overview
Performance year Payment year Annual Payment update No Participation Adjustment factor Submit Something (≥ 3 points)

Adjustment factor

Partial Participation Adjustment factor Full Participation Adjustment factor Exceptional Bonus

(≥ 70 points)

Payment Adjustment

2017 0.5% 0 0 0 0 0
2018 0.5% 0 0 0 0 0
2017 2019 0.5% -4% 0% 0% to 4% +-4% ≤10%

If a provider does not participate (submits no data), Medicare is required to give a zero performance score with a negative payment adjustment of 4%. Medicare states that to receive a neutral payment adjustment, a provider needs to score at least three points by submitting some data. A provider needs to score ≥70 points to receive the exceptional bonus payment.

The MIPS adjustment factor will be calculated with the MPFS Conversion Factor (“CF”) to determine the Medicare payment. The following equation illustrates the Medicare payment calculation through the QPP MIPS track:

Medicare Physician Fee ScheduleXMIPS Adjustment Factor= QPP Medicare Payment

In summary, Eligible Clinicians need to be aware of the following:

  • MACRA website – qpp.cms.gov
  • MACRA is not the same as ACA. MACRA replaces the Medicare SGR method with a value-based reimbursement system.
  • CY 2017 is a transition year, allowing Eligible Clinicians –
  • two QPP tracks, MIPS and APMs,
  • four MIPS options for participation to transition into QPP
  • Who qualifies as an Eligible Clinician under the QPP MIPS track.
  • How an Eligible Clinician compared to peers on the QRUR.

CMS is making an all-out effort to educate Medicare providers by developing a dedicated website to provide education and easier access to MIPS category measures. CMS is allowing the provider the opportunity to “transition” into data submission at the provider’s “pace.”

Elliott Davis Decosimo’s healthcare team is willing and able to provide assistance and find answers for you if you feel overwhelmed by the new Medicare payment program.

This information was taken from and may be reviewed at www.qpp.cms.gov

Find the prior Elliott Davis Decosimo article on our website, http://www.elliottdavis.com/articles/healthcare-alert-macra-me