What is MACRA?

MACRA is the Medicare Access and CHIP Reauthorization Act of 2015, which was finalized on October 14, 2016. MACRA is Medicare’s most recent initiative to directly tie Medicare payments to patient quality outcomes since the Department of Health and Human Services (HHS) began launching quality initiatives in 2001. MACRA’s first performance year begins January 1, 2017 and will have a significant impact on all healthcare providers’ reimbursement. It is more important now than ever before to take the appropriate steps to maximize your potential for increased revenue and mitigate your risks of payment decreases.

What are the two payment models presented in MACRA?

  • Advanced Alternative Payment Models (Advanced APMs)
  • Merit-based Incentive Payment Systems (MIPS)

Medicare’s Quality Payment Program (QPP) is a product of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). QPP is 1 component of the reinvention of how Medicare will pay its Part B providers following the end of the Sustainable Growth Rate formula methodologyMIPS or APMs

Who is eligible?

A provider who bills Medicare Part B >$30k/ yr. for care to >100 Medicare patients/ yr. as a:

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist

Advanced Alternative Payment Models (Advanced APMs)

Advanced APMs are a subset of APMs created to allow practices to earn more reimbursement in exchange for an increased risk based on patient outcomes. By participating in an Advanced APM, a provider can potentially earn a 5% incentive payment.

To learn more about how to apply for an Advanced APM, you can visit https://qpp.cms.gov/learn/apms to further explore existing and new alternative payment models across the country.

Merit-based Incentive Payment Systems (MIPS)

The vast majority of providers will be eligible to participate in MIPS in 2017. MIPS will effectively merge many of the current quality programs that healthcare providers are familiar with, including Meaningful Use (MU), Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM).

1. Noted Changes in MIPS from 2017 to 2018

  • Performance threshold raised to 15 points in Year 2 (vs. 3 points in 2017 transition year).
  • MIPS Cost Category weight increased from 0% to 10% and the MIPS Quality Category decreased from 60% to 50%
  • Low volume eligibility threshold raised from $30,000 to $90,000 and from 100 patients to 200 patients
  • Minimum reporting period expanded from 90 days to full calendar year

2. Complaints by Providers

On April 20, 2018, 50 provider groups sent letters to the Center for Medicare and Medicaid Services (CMS) urging them to reduce the reporting period from a full calendar year to 90 days for calendar year 2018 citing they are being held accountable for data tracking beginning January 1, 2018, but were not informed of eligibility information until April 6, 2018.

The provider letters highlighted four key concerns:

  • “Undersigned organizations strongly support the increased low-volume threshold and believe it will assist small practices and physicians who treat a small number of Medicare patients, but CMS may create changes in physicians’ eligibility status,” the provider groups contended.
  • Without direct outreach by CMS to physicians and group practices, many physicians will be left in the dark on their status.
  • “We acknowledge that certain reporting options, such as reporting certain outcome-based measures, may require a lengthier reporting period than 90 days. To ensure statistical validity, we believe there is a substantial opportunity to reduce the cost and labor involved in reporting MIPS data to CMS by shortening the minimum data collection period to 90 consecutive days and allowing physicians to decide whether to report additional data,” they wrote.
  • “It is our understanding that CMS does not plan to update the website until the summer, at the earliest, which is halfway through the reporting period,” they explained. “Given the Quality Payment Program (QPP) website is the primary means for educating physicians on the program, this severe delay will undermine physicians’ ability to meet the 2018 requirements to successfully avoid a penalty.”

3. Possible Replacement for MIPS

The Medicare Payment Advisory Commission (MedPAC), a nonpartisan legislative branch agency that provides United States Congress with analysis and policy advice on the Medicare program, voted 14-2 to replace MIPS with the Voluntary Value Program (VVP) in January 2018. The VVP would apply to all Medicare providers, essentially giving them the option to voluntarily participate in an Accountable Care Organization (ACO), alternative payment model or other group OR lose 2% of Medicare reimbursement.

Opposition to the Med PAC-VPP revolves around 2 unanswered questions

  1. Will ACOs, alternative payment models or other groups be available for doctors to join if they want to avoid the 2% penalty?
  2. Will “groups” that treat sicker and poorer patients suffer?

Obviously, MIPS is fluid and ever-changing. It’s imperative that providers stay up-to-date on the most recent changes to ensure compliance with MIPS.

Selecting and Reporting MIPS Measures

Measure Selection: Which MIPS measures should your organization report?

  1. Analyze provider/practice utilization to understand the patient population (i.e., conditions treated, services rendered, etc.).
  2. Evaluate existing technology to determine data capture and reporting readiness for relevant measures.
  3. Interview key personnel to further understand the aspects of MIPS most meaningful to the provider/practice (i.e., as may align to measures within each of quality, CPIA, ACI, cost and resource use).
  4. Determine ACI exemption eligibility (e.g., ≥75% hospital-based services, ≤100 “patient-facing” encounters).
  5. Recommend specific MIPS measures for participation.

Readiness Assessment: What do you need to do to prepare for MIPS?

  1. Evaluate the level of staff and clinician MIPS awareness.
  2. Evaluate existing PQRS and MU processes for capture and reporting[1].
  3. Review 2015 QRUR to understand existing cost and quality measure performance[2].
  4. Determine EHR-reporting eligibility (i.e., 2014 or 2015 edition)[3].
  5. Identify high-performing areas and areas to be strengthened.
  6. Recommend reporting submission method (e.g., claims, qualified registries, certified EHR technology).

Score Calculation: How will you score MIPS?

  1. Generate a sample report of the required data for all chosen MIPS measures for a minimum 90 day period and generated by the selected reporting submission method.
  2. Evaluate the complete and accurate reporting of each measure.
  3. Calculate Quality score for the sample measure set up to 80-90 points (depending on group size) towards 60% of the overall MIPS score (or 85% if ACI-exempt).
  4. Calculate ACI score for the sample measure set up to 100 points towards 25% of the overall MIPS score (or 0% if ACI-exempt).
  5. Calculate CPIA score for the sample measure set up to 40 points towards 15% of the overall MIPS score.
  6. Calculate overall sample MIPS score to ensure neutral participation at a minimum, or at the required level to meet higher-performing provider/practice goals.

[1] Physician Quality Reporting System (PQRS) (http://go.cms.gov/2aGFy3H); Meaningful Use (MU) (http://go.cms.gov/1W9LsJu)

[2] 2015 Quality and Resource Use Report (QRUR) (http://go.cms.gov/26fCfWE)

[3] 2014 Edition Electronic Health Record (EHR) Certification Criteria (http://bit.ly/2dP4Eza); 2015 Edition EHR Certification Criteria (http://bit.ly/2e3G0IP)

MIPS Scoring Methodology

Each MIPS provider will receive a MIPS Score based on the following categories:

Performance Category

% of Total Score

Quality (replaces PQRS)


Advancing Care Information (ACI) (replaces MU)


Clinical Practice Improvement Activities (CPIA) (new category)


Cost (replaces VBM)


CMS estimates approximately 90% of MIPS eligible clinicians will receive a positive or neutral payment adjustment. The below table illustrates the point system and associated (+/-) adjustment for 2017.

Final Score

MIPS Adjustment

0-0.75 -4%
0.76-2.9 Negative adjustment greater than -4% and less than zero
3.0 0%
3.1-69.9 Positive adjustment greater than 0 up to 4%
70-100 Positive adjustment (maximum) up to 4%, plus exceptional performance adjustment (greater than .5% up to 10%)

As physician practices look to close out the new year and begin planning for 2017, it will be imperative to have processes in place that capture the opportunity for increased revenue potential under this new ruling. With advanced planning, having a clear understanding and taking appropriate steps will allow you to mitigate risks for decreased payments and maximize opportunity for enhanced revenue. But, time is of the essence. Each day that goes by without a clear strategy can result in money being left on the table, so consult an expert today to put the right processes in place.

MIPS Options for Providers

MACRA’s Final Rule has declared 2017 as a Transition Year to allow providers to “pick their pace” of participation for MIPS first performance period. As such, clinicians may choose from the following options:

2017 Reporting Options

  1. Clinicians can choose to report in each performance category for a full 90-day period
  2. Clinicians can choose to report in each performance category for the full calendar year


  3. Clinicians can avoid a negative (-4%) payment adjustment by reporting one of the following for a full 90-day period in 2017:
    • One Quality measure
    • One ACI measure
    • One CPIA measure

LBMC can assist in the selection and reporting of MIPS measures that:

  • drive most important outcomes for your practice
  • are well aligned with your clinical workflows
  • are not burdensome to capture and report via existing resources