Medicare Reform Rundown. By: Tiffany Lotridge, MBA- Consultant

Medicare Reform Rundown. By: Tiffany Lotridge, MBA- Consultant

MACRA, which is the Medicare Access and CHIP Reauthorization Act of 2015 is a bill passed by congress outlining the new Medicare payment system and Quality Payment Program (QPP) guidelines. This law redefines the Medicare reimbursement amounts based on the quality of care and frequency of treatments/episodes of care for Medicare recipients. With its passing, this act also amends the Title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and strengthen Medicare access by improving physician payments for services and making other vital improvements. The new QPP that MACRA outlines offers two methods for physician reimbursement, Alternative Payment Models and the Merit-based Incentive Payment System otherwise known as MIPS.

But what does it all mean? How do you know what payment model to choose for your organization?

An organization will determine what reporting method to use based on their size, specialty, location and patient population/demographics. Each payment method has criteria that must be met in order to determine what method to use.

  • The Alternative Payment Model (APM) breaks down further into two categories; regular APMs or Advances APMs. To be able to report as an APM the practice must be using a certified electronic health record technology (CEHRT), provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS, and either a Medical Home Model or require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses.
  • Merit-based Incentive Payment System. To be able to report under MIPS, the practice must bill more than $30,000 a year in approved Medicare charges and be providing care to more than 100 Medicare patients a year and be a physician, PA, CNP, clinical nurse specialist or a certified registered nurse anesthetist. There are some exclusions with MIPS; clinicians who are newly enrolled Medicare providers (who enrolled during the reporting period) are excluded from MIPS the year of their enrollment. Also, clinicians below the low-volume threshold (bill less than $30,000 in approved Medicare charges or see less than 100 Medicare patients a year), or if you are a clinician participating in an APM.

MIPS Data Requirements:

  • Quality Data (60%): Most participants will report up to 6 quality measures including an outcome measure, for a minimum of 90 days.
  • Improvement Activity Data (15%): Most participants will report 4 improvement activities for a minimum of 90 days.
  • Advancing Care Information Data (25%): This reporting data replaces the former Medicare HER Incentive Program also known as Meaningful Use
  • Please note: Clinicians are not required to report their yearly cost for EMR, data collection, patient care supplies or cost to run their facility.
  • MIPS APMs are entities that meet the criteria of both an APM and MIPS. These entities meet the partial QP threshold and elect to participate in MIPS. This will be few and far between. Most Medicare providers will report under MIPS.

By 2018 all providers and their organizations should be familiar and have already participated in either QPP in 2017, unless you were willing to accept the penalty for not reporting or did not meet the reporting requirements. However, with the ever changing climate of the healthcare industry and our government, MACRA is anticipated to be changing many times over the next couple of years, with addressing its complexity being at the forefront of issues to attend to. The Healthcare Consultants at The Shealy Group are staying informed and are ready to roll with the punches of these anticipated changes alongside our clients who will be affected. We can help you stay informed as well! For more information as it becomes available, follow The Shealy Group on Facebook, Twitter and LinkedIn or sign up for our monthly e-newsletter by clicking here!