MACRA: What You Need To Know

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Value Based Services

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MACRA (The Medicare Access & Chip Reauthorization Act of 2015) is coming…

What’s The Big Idea?
In April, The Centers for Medicare & Medicaid Services (CMS) released the Notice of Proposed Rulemaking that will alter regulations on how Medicare reimburses Eligible Clinicians and their practices beginning in 2017. With a stronger emphasis on quality, value, and bigger financial risk, there are three key areas MACRA seeks to address:

  1. Repealing the Sustainable Growth Rate (SGR)
  2. Extending the Children’s Health Insurance Program (CHIP)
  3. Shifting from fee-for-service to pay-for-performance

MACRA’s Quality Payment Program will allow practitioners to select between two quality payment program options:

Less than 10% of ACOs currently qualify as Advanced APMs and therefore most practices will participate in MIPS. Since most Eligible Clinicians will be participating in MIPS, we will delve deeper into this Quality Payment Program option.

When Will MIPS Begin?
MIPS is scheduled to begin in 2017 as its first performance year so there will be no change to MU, PQRS, and VM in 2016. The final ruling is expected by November. While the first reporting year for MIPS is scheduled for 2017, payment adjustments will be based on a two-year look back period: starting in 2019, payment adjustments will be applied based on 2017 performance.

Example: A MIPS Eligible Clinician that has a better than average MIPS score for the 2017 reporting year may be eligible for a positive payment adjustment in 2019.

Click here to learn more about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Who Does MIPS Affect?
Eligible Clinicians in 2017 and 2018 include:

Then, Eligible Clinicians in 2019 include:

Furthermore, non-patient facing Eligible Clinicians must also participate in MIPS. A non-patient facing Eligible Clinician includes clinicians or groups that have fewer than 25 patient-facing encounters during a particular reporting period, including telehealth services. If an Eligible Clinician has more than 25 patient-facing encounters, they are considered a traditional MIPS eligible clinician.

The following exclusions are available:

Major Changes From Existing Categories

What Is MIPS All About?
Previously, there were three stand-alone programs: MU, PQRS, and VM. MIPS will combine these programs and be comprised of four program categories: quality, resource use/cost, advancing care information, and clinical practice improvement.

How Will MIPS Be Scored?
MACRA will allow MIPS measures and activities to be converted into points that calculate the MIPS Composite Performance Score.

Composite Performance Score
Composite Performace Score for MIPS

More Exciting Changes
MACRA proposes more exciting reporting options, including individual or group reporting options. According to CMS, an individual is identified by the Eligible Clinician’s tax ID and NPI combination. A group will be defined by taxpayer identification number. It is important to note that Eligible Clinicians can report as a group across all four MIPS performance categories or as an individual across all four MIPS performance categories. Practices cannot report as an individual for some categories and as a group for others.

There are also several new data submission options, but MIPS Eligible Clinicians and groups may only use one submission mechanism per category. MACRA grants practices more flexibility by allowing practices several ways of submitting their data and eliminating the previous “all or nothing” performance evaluations.

What’s Next?
TSI Healthcare recommends the following in preparation:

TSI Healthcare understands how challenging it can be to navigate various government regulations. We are committed to partnering with our clients to keep you up to date as CMS’s Quality Payment Program evolves. To learn more about MACRA, view our infographic below or visit

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