Think of the last time you had a calm day at your medical practice. If you can’t remember one, that might be because you’re operating on a traditional fee-for-service model requiring you to see as many patients as possible to turn a profit. Many doctors aren’t thrilled about this model, and neither are policymakers. That’s why the federal government enacted a law called MACRA in 2015, creating the MIPS program that shifts certain practitioners away from the fee-for-service model. Learn all about MACRA and MIPS below.
MACRA is an acronym for the Medicare Access and CHIP Reauthorization Act. (CHIP stands for the Children’s Health Insurance Program.) This federal statute went into effect in 2015 and changed how medical practices get reimbursed when they provide care to Medicare patients. It shifts Medicare providers from a traditional fee-for-service model to a potentially more progressive value-based healthcare approach.
According to the Centers for Medicare and Medicaid Services (CMS), MACRA rewards practitioners for the quality of care they provide, rather than the amount. This definition falls in line with widely accepted notions of value-based care.
Upon taking effect, MACRA replaced the Value-Based Modifier (VBM), Medicare Electronic Health Record (EHR) Incentive Program and Physician Quality Reporting System (PQRS). MACRA kept many key components of these programs and combined them into one: the Quality Payment Program (QPP). Within the QPP are two paths for practitioner reimbursement: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Your practice should become familiar with the latter.
MACRA is a federal law that introduced the MIPS model for practitioner reimbursement in 2015.
MIPS determines how much money Medicare pays your practice for its services. It gives your practice a composite performance score that affects how much Medicare pays you. Your score will range from zero to 100 and depends on four factors: quality, promoting interoperability, improvement activities and cost.
Note that all the above percentages can change if you file an exception application or participate in an APM instead of MIPS. They can also change if CMS gives you a special status. Additionally, if you don’t see enough patients to meet any of the cost metric’s qualifications, cost will not be a part of your MIPS score. CMS will distribute its 30% weight to other factors.
MIPS changes the amount that Medicare reimburses you based on your care’s quality and cost, as well as your practice’s interoperability and improvement measures.
MACRA and MIPS affect the following practice and practitioner considerations.
In theory, all the above criteria mean that if you see Medicare patients, you qualify for MIPS. In reality, that’s not quite true. Some practices don’t qualify for MIPS. Below all are the qualification factors.
CMS automatically qualifies the below types of practitioners for MIPS. If you fall outside these categories, you may not qualify for MIPS:
If you’re an individual clinician, you qualify for MIPS if the following statements are true:
The rules are mostly the same if you practice as part of a group. The only difference is that your group, not you alone, must exceed the low-volume threshold. This rule also applies to virtual practice groups. Additionally, if you or your group meets only one or two of the three low-volume criteria (detailed below), you can opt in to MIPS. Doing so wouldn’t be required in that case, but it could lead to higher reimbursements.
Your practice volume at the end of your MIPS determination period will also be a factor in whether or not you qualify. If you meet the following criteria, your practice exceeds the low-volume threshold and qualifies for MIPS:
Note that any individual practitioner who qualifies for MIPS must report data to CMS. Opt-in practitioners can choose whether or not to do so. Whether you’re reporting MIPS data because you’re required to or because you have chosen to, the potentially higher reimbursements could be worth your while.