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In short, it is the beginning of a transition to value-based care, otherwise known as pay-for-performance. It changes the way that Medicare rewards clinicians for value over volume.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the most significant piece of healthcare legislation since the Affordable Care Act in 2010. It establishes a Quality Payment Program (QPP), an incentive program that consists of two payment tracks: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Performance measurements for the QPP began on January 1, 2017.
If you are a physician who provides services to patients that you bill for under the Medicare Physician Fee Schedule (i.e., if you see “traditional” Medicare patients), you are likely subject to the QPP.
The QPP applies to Physicians, including doctors of: medicine, osteopathy, osteopathic practitioners, dental surgery, dental medicine, podiatric medicine, optometry, and chiropractors, Physicians Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNS), Certified Registered Nurse Anesthetists (CRNSs), Physical Therapists, Occupational Therapists, Qualified Speech-Language Pathologists, Qualified Audiologists, Clinical Psychologists, Registered dietitian or nutrition professionals and groups of such clinicians.. An Eligible Clinician (EC) is any provider who sees greater than 200 Medicare patients and bill more than $90,000 in Medicare Part B Allowed charges and provide more than 200 covered professional services to Part B patients. If a provider exceeds only one or two of the three above criteria, they do have the option to elect to opt-in.
Under the QPP, physicians are rewarded for providing high-quality, low-cost care and for engaging in quality improvement activities. Many of these activities are already a part of your practice workflow, and you will now be compensated for their contributions to quality patient care.
Unless you qualify for an exemption from MIPS in 2020, you will receive a -9% payment adjustment to your Medicare Part B fee-for-service (FFS) claims in 2022 if you do not participate.
CMS no longer offers the “test” and “partial” participation options that were available as part of the 2017 transition year policies. Physicians’ MIPS scores are determined on their overall performance in each of the four MIPS categories compared to the CMS performance threshold score for a given year. Physicians will receive a score in each category, and their MIPS final score will be the sum of the weighted score of each category.
Use the CMS NPI lookup tool to help you determine your eligibility. To use the tool, you will need to know your 10-digit national provider identification (NPI) number.
Providers that participate in non-advanced APMs or advanced models that do not achieve qualifying thresholds fall under the “MIPS APM” category. These providers must participate in MIPS but are exempt from some of the reporting requirements while earning additional points in others.
