The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula for Medicare reimbursement. For eligible clinicians, the Quality Payment Program (QPP) replaces previous Medicare Part B payment programs with the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Explore information and resources to learn how this affects your practice. Questions? Email us at firstname.lastname@example.org.
What is MACRA?
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is legislation that established a new payment system for doctors who treat Medicare patients, changing the way Medicare doctors are reimbursed. Under MACRA, the Sustainable Growth Rate (SGR) Formula was repealed, and providers are instead paid based on the quality and effectiveness of the care they provide.
What is the Quality Payment Program?
Quality Payment Program (QPP) is the name of the Medicare payment program set in place by MACRA. QPP allows Medicare providers to choose one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).
How does this affect me or my practice?
You can find out whether you are part of the QPP by entering your provider number into the tool on this page: qpp.cms.gov/learn/eligibility. Providers are part of the QPP if:
You participate in an Advanced APM or
You bill Medicare more than $90,000 in Part B allowed charges per year OR provide care for more than 200 Medicare patients per year
There is additional technical support available for practices in Small, Rural and Health Professional Shortage Areas (HPSAs). If you meet the eligibility requirements above, you must begin participation in the QPP on January 1 of the reporting year. Performance data for Year 1 must be submitted by March 31, 2018 in order to avoid a payment penalty.
Understanding the Measurement Criteria and Reporting Requirements
The Merit-based Incentive Payment System (MIPS) uses performance-based measures to determine Medicare payment adjustments. Medicare will use the four categories below to determine whether eligible physicians participating in MIPS will receive a positive, negative, or neutral payment adjustment to their Medicare payments. Click on the icons below to select and download the measurement CSV files for Quality, Advancing Care Information, and Improvement Activities. For Year 2, the categories will be weighted as follows:
Replaces PQRS. Report at least six measures for the full calendar year.
Advancing Care Information (25%)
Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.
Improvement Activities (15%)
110+ activities focused on care coordination, beneficiary engagement, and patient safety. Attest that you completed up to 4 Improvement Activities for a minimum of 90 days.
Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.
Pick Your Pace
"Pick Your Pace" was a transition period in 2017 that allowed eligible clinicians participating in MIPS to choose when and how to begin participation. Data will be evaluated in 2018, and payment adjustments will be applied to 2019. Failure to submit data by March 31, 2018 will result in a 4% decrease in Medicare Part B payments in 2019. Participants have three options for 2017 performance data collection:
Test: Submit a minimal amount of data to avoid penalties.
Partial: Submit 90 days of performance data to avoid penalties and earn a neutral or modest increase in payment.
Full: Submit a full year of performance data to avoid penalties and earn up to a 5% increase in payment.
Participating in Advanced APMs
You may be exempt from MIPS if you participate in an alternative payment model. Alternative Payment Models (APMs) are payment approaches that give incentives for high-quality and cost-efficient care. Advanced APMs are a type of APM that allow practices to take on some risk related to patient outcomes. To find Advanced APMs accepting enrollment, please visit innovation.cms.gov.
In 2018, clinicians who participate in one of the Advanced APMs listed below will be exempt from the MIPS reporting requirements and will receive a 5% payment bonus from 2019 – 2024. If you leave an Advanced APM during 2018, make sure you have met the Advanced APM threshold or submit MIPS data to avoid a penalty.
Medicare Access and CHIP Reauthorization Act of 2015 is landmark legislation that changes how Medicare pays physicians.
Quality Payment Program is the new Medicare Part B payment program focused on care quality.
Merit-based Incentive Payment System is the payment system for eligible clinicians who are not participating in an Advanced APM. The payments in MIPS are based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost.
An Advanced Payment Model is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.
Advanced Alternative Payment Models are a subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.
Centers for Medicare & Medicaid Services is a US federal agency under the Department of Health and Human Services which administers Medicare, Medicaid, and the State Children's Health Insurance Program.
United States Department of Health and Human Services