FAQ on MACRA and Medicare Payment Reform
New: 2019 MIPS Playbook
Get the AAFP's newest guide to navigating the Merit-based Incentive Payment System (MIPS)..
Free for Members
FAQ on MACRA and Medicare Payment Reform
Frequently Asked Questions: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
New: 2019 MIPS Playbook
Get the AAFP's newest guide to navigating the Merit-based Incentive Payment System (MIPS)..
Free for Members
At a very high level, MACRA:
- Repealed the flawed Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians;
- Created a new framework for rewarding physicians for providing higher quality care by establishing two tracks for Medicare payment:
- Consolidated three previous quality reporting programs [Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), and meaningful use (MU)], plus added a new performance category, called improvement activities (IA), into a single system through MIPS.
The Merit-based Incentive Payment System (MIPS) consolidates previous quality reporting programs. The system also added a new performance category, called improvement activities (IA). Scores from the four categories are combined to establish a final score (0-100) that will be compared against a threshold. The final score is then used to determine physician payment adjustments. The categories that make up the MIPS final score are:
- Quality—based on PQRS;
- Cost—based on VBPM;
- Promoting Interoperability (PI)—based on MU; and
- Improvement activities—new performance category.
Scores for each performance category will be weighted and rolled up into the MIPS final score. The weights of each category shift over the course of the program.
MIPS final scores will be published by the Centers for Medicare & Medicaid (CMS) on the Physician Compare website(www.medicare.gov).
All MIPS-eligible clinicians (ECs), regardless of specialty, will be compared to each other and against a performance threshold.
ECs in a large multispecialty group can report either as an individual or as a group. When reporting as a group, all ECs reporting under the group’s tax identification number (TIN) will be included. A group cannot have some ECs report as a group and others report as individuals. Under the group reporting option, all ECs will report on the same measures. If you choose to report as a group, you must report as a group across all four MIPS performance categories.
Physicians who have opted out of Medicare and do not accept payments from Medicare will not be affected by payment adjustments in MIPS.
Yes. While most employed physicians will report as part of a group, MIPS payment adjustments are applied at the national provider identifier (NPI) level. If an employed physician changes practices between the performance period and the payment year, the physician’s MIPS score and accompanying payment adjustment will apply to payment at the new practice. When making hiring decisions, potential employers may take your MIPS final score into consideration.
Additionally, employers may begin basing your compensation on your MIPS final score. Employed physicians will want to make sure they are appropriately compensated for a high MIPS score.
Reporting methods for individuals include: claims, qualified clinical data registry (QCDR), qualified registry, and electronic health records (EHR). The promoting interoperability and improvement activities categories will include attestation options through the CMS Portal(qpp.cms.gov). There is no data submission for the cost performance category, as CMS will calculate this for ECs based on Medicare claims data.
Reporting methods for groups include: claims (15 or fewer ECs only), QCDR, qualified registry, EHR, CMS Web Interface (25+ ECs), and CMS-approved survey vendor for the Consumer Assessment of Health Providers and Surveys (CAHPS) for MIPS. Groups will also be able to attest for the promoting interoperability and improvement activities performance categories. The CMS Web Interface option is only available to report the quality category.
Eligible clinicians can find approved qualified registry and QCDR vendors in the QPP resource library(www.cms.gov). ECs can find out if their EHR is certified by searching the Certified Health IT Product List (CHPL)(chpl.healthit.gov).
Solo and group practices (10 or fewer NPIs) can join together to participate in MIPS as a virtual group. A virtual group must consist of at least two TINs. Virtual groups are designed to help small practices successfully participate in MIPS.
In the quality performance category, you must report at least six measures, including one outcome measure. ECs must report on at least 60% of patients eligible for the measure, regardless of payer. This is referred to as “data completeness criteria.”
In addition to the six measures reported by ECs, CMS will calculate the all-cause hospital readmission measure for groups of 16 or more ECs.
There is no reporting requirement for ECs under the cost category. CMS will calculate the clinician’s performance using claims data. Cost accounts for 15% of the MIPS final score for the 2019 performance period. Clinicians will be assessed on their performance of Total per Capita Cost, Medicare Spending per Beneficiary (MSPB), and applicable episode-based measures. CMS is currently developing additional episode-based cost measures for use in future program years.
Certified or recognized patient-centered medical homes (PCMH) will receive full credit in the improvement activities category. Organizations which currently offer approved PCMH accreditation include:
- National Committee for Quality Assurance (NCQA)
- Accreditation Association for Ambulatory Health Care (AAAHC)
- Joint Commission (previously called the Joint Commission on Accreditation of Healthcare Organizations)
- URAC (previously called the Utilization Review Accreditation Commission)
- State-based, regional, private payers, or other entities that administer PCMH accreditation to at least 500 practices
Additionally, if at least 50% of practice sites under the TIN have PCMH recognition, the entire TIN will qualify for full points in the improvement activities performance category.
Clinicians who do not qualify for the full credit must attest to two high-weighted (20 points each) or four medium-weighted (10 points each) activities, or a combination of both to achieve a total of 40 points. An activity must be performed for at least 90 consecutive days during the performance period to receive credit.
To ease the burden for small practices (15 or fewer ECs), practices in rural areas or health professional shortage areas (HPSAs), CMS is only requiring submission of one high-weighted activity or two medium-weighted activities.
For MIPS APMs, CMS will assign a score in the improvement activities performance category based on improvement activity requirements under the terms of the particular MIPS APM. If CMS assigns the maximum score, then MIPS APM participants would not need to submit additional activities. If the MIPS APM does not receive the maximum score, the participants would have the opportunity to submit additional activities to be added to the baseline score assigned to CMS. All other APMs will automatically receive half the credit for the improvement activities performance category.
CMS redesigned the PI performance category. Scores for this category are based on an EC or group's performance on a set of required measures. An EC cannot earn more than 100 points (100%) in the PI performance category. ECs must report a minimum 90 consecutive days for the PI category.
The objectives and measures are based on the 2015 EHR Incentive Program requirements. Beginning in 2019, ECs must have 2015 Edition certified electronic health record technology (CEHRT) in place for the PI performance period.
*This category was formerly called advancing care information (ACI).
Clinicians without an EHR can still participate in MIPS, but will not be eligible for any of the points under the PI performance category. Use of EHR technology that is not certified will result in a zero for the category.
While still possible to participate in MIPS without an EHR, the reporting requirements will be more burdensome without the use of an EHR. The reporting mechanisms available to a practice without an EHR would be claims or qualified registry. However, use of the qualified registry option would require a manual data collection process. This would require reporting on at least 60% of the clinician’s denominator-eligible patients.
For the 2019 performance period (2021 payment year) physicians participating in MIPS will be eligible for positive or negative Medicare Part B payment adjustments of up to 7%. Distribution of payment adjustments will be made on a sliding scale and will be budget neutral. Payment adjustments will be based on the following:
- Physicians with a final score at the threshold (30) will receive a neutral payment adjustment.
- Physicians with a final score above the threshold (>30) will receive a positive payment adjustment on each Medicare Part B claim in the payment year.
- Physicians with a final score below the threshold (7.51-29.99) will receive a negative payment adjustment on each Medicare Part B claim in the payment year.
- Physicians with a final score in the lowest quartile (≤7.5) will automatically be adjusted to the maximum negative adjustment on each Medicare Part B claim in the payment year.
The Centers for Medicare & Medicaid Services will apply the MIPS payment adjustment at the TIN/NPI level. ECs who reported as a group will all receive the same final score, but the payment adjustment will be applied at the TIN/NPI level. Payment adjustments are made at the Medicare Part B claim level.
If an EC bills under more than one TIN during the performance period, CMS will use the highest final score associated with the clinician’s NPI during the performance period to adjust payment in the payment year.
If a clinician changes TINs between the performance period and payment year, CMS will apply the final score associated with the clinician’s NPI during the performance period to the new TIN/NPI combination. For example, if a clinician practiced at TIN A during the performance period, but is practicing at TIN B during the payment year, CMS will use the final score from TIN A to apply to the payment adjustment to the new TIN B.
Physicians can submit a request for a targeted review if they believe the information submitted to CMS has calculation errors, data quality issues, or if they clinician believes CMS has made errors in assigning score to MIPS-eligible clinicians (e.g., MIPS-eligible clinicians should have been subjected to the low-volume threshold).
Yes. Exclusions from MIPS include:
- Clinicians in their first year billing Medicare;
- Clinicians with their volume of Medicare payments or patients falling below the low-volume threshold (200 Medicare Part B patients OR $90,000 or less in Medicare Part B charges) OR 200 Medicare Part B services); and
- Clinicians who qualify for a bonus payment under AAPMs.
Clinicians can check their MIPS-eligibility and Qualifying AAPM Participant (QP) status using the QPP Participation Status Tool(qpp.cms.gov).
Clinicians that meet or exceed one or two, but not all, of the low-volume threshold criteria can opt-in to participate in MIPS. Clinicians who opt-in are eligible for positive and negative payment adjustments. Opt-in elections must be made through the QPP Portal and are in effect for the applicable performance year (i.e., they cannot be rescinded).
Resident physicians in their second year of Medicare billing and who are billing under their own NPI would be subject to MIPS adjustments. Resident physicians in their first year of billing would be considered new to Medicare and excluded from MIPS.
Payments for items and services made under a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) all-inclusive payment are exempt from MIPS. However, any Medicare Part B items and services provided and billed outside of the all-inclusive payment at FQHCs and RHCs will be subject to MIPS payment adjustments. FQHCs and RHCs are still subject to the low-volume threshold.
The low-volume threshold is calculated at the participation level of the EC. If reporting as a group, the low-volume threshold would be calculated at the group level. If reporting as an individual, the low-volume threshold would be calculated at the individual level.
The Centers for Medicare & Medicaid Services will calculate an EC’s low-volume threshold status using two sets of claims data. For the 2019 performance period, the first data set will include claims data from October 1, 2017, to September 30, 2018. The second data set will include claims data from October 1, 2018, to September 30, 2019. CMS will not change the low-volume status of ECs who fall below the low-volume threshold during the first review period, but not the second. ECs can check their MIPS-eligibility status using the QPP Participation Status tool(qpp.cms.gov).
The Centers for Medicare & Medicaid Services defines a small practice as 15 or fewer ECs (small practice size for virtual groups is 10 or fewer ECs). This may include NPIs excluded from MIPS. CMS determines small practice status by analyzing claims, using the same dates as those used for determining low-volume threshold status. Small practice determinations will be available through the QPP Participation Status tool(qpp.cms.gov).
There are two hardship exceptions available to ECs. This includes a significant hardship exception for the promoting interoperability category and an extreme and uncontrollable circumstances (e.g., natural disaster) exception for the quality, cost, and improvement activities categories.
A MIPS APM includes APMs that did not qualify as AAPMs. MIPS APMs do not qualify as AAPMs because they either do not meet the nominal risk criteria or the AAPM participants do not meet the payment or patient thresholds. CMS will apply an “APM Scoring Standard” to ECs participating in MIPS APMs. The APM Scoring Standard will also be applied to clinicians who did not meet QP thresholds, and are determined to be partial QPs who elect to participate in MIPS (although participation is optional). For the 2019 performance period, MIPS APMs include:
- Comprehensive Primary Care Plus (CPC+)
- Medicare Shared Savings Program (MSSP) Tracks 1, 2, and 3
- Medicare Accountable Care Organization (ACO) Track 1+
- Next Generation ACO Model
- Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
- Maryland Primary Care Model
- Additional models will be announced by CMS as they are approved
There is $20 million per year allocated to provide technical assistance through the QPP Small, Underserved, and Rural Support (SURS) program to practices with 15 or fewer ECs participating in MIPS. This assistance is intended to assist practices in a successful transition into the MIPS payment pathway. Priority will be given to practices in rural areas and health professional shortage areas (HPSAs).
For practices that do not qualify for the MACRA technical assistance, there is the Transforming Clinical Practice initiative (TCPi). This program launched in September 2015 to position practices for participation in alternative payment models. Practice Transformation Networks (PTNs) are available across the country to provide coaching, resources, and tools to help practices prepare for value-based payment models. Call (866) 288-8292 to connect with a PTN near you.
As always, we’re committed to keeping you informed, developing resources to support your quality improvement efforts, and helping you provide cost-effective care. As information, tools, and resources to help you comply with and benefit from MACRA become available, we will update AAFP.org and spread the word through AAFP News and Family Practice Management (FPM).
We will continue to advocate vigorously for the following:
- Improved payment for primary care;
- Administrative simplification, including reducing prior authorizations;
- Harmonization of measures across all private and public payers through the use of the Core Quality Measure Collaborative Core Measures Set; and
- Reasonable reporting requirements
The AAFP has highlighted a series of care management services that provide an opportunity to increase revenue to support practice transformation or quality improvement projects. These services provide an opportunity for you to generate revenue while preparing for MIPS.
These services include Medicare’s Annual Wellness Visit (AWV), Chronic Care Management (CCM), Transitional Care Management (TCM), and Advance Care Planning (ACP). Find more information and resources to help you implement these services.
Information, tools, and resources to help you comply with and benefit from MACRA are available from the AAFP and from FPM. We encourage you to bookmark our MACRA Ready landing page for quick access to up-to-date news and resources.
The latest news about MACRA and other payment reform topics is available from AAFP News.
AAFP members can contact an AAFP subject matter expert or call (800) 274-2237.
Last updated: February 2019