Have you decided which MACRA participation option your practice will choose in the 2017 transition year? What you choose now (and how you implement that choice) determines your payment adjustment for Medicare Part B billings in 2019 and beyond.


Oh yes, the election.  As you have undoubtedly heard, the President-elect has promised to do away with the Affordable Care Act (ACA). It is still unclear whether Congress will act to completely repeal the ACA or, more likely, strip it or defund parts of it that are unpopular. That said, the Medicare Access and CHIP Reauthorization Act (MACRA) is a separate piece of legislation, passed with bipartisan support, and though it will evolve, there is no indication as of now that it will be significantly changed or repealed. That means that January 1, 2017 still marks the beginning of its implementation.


Medicare clinicians have two options for participation in the Medicare Access and CHIP Reauthorization Act (MACRA):

  1. Merit-Based Incentive Payment System (MIPS), and
  2. Advanced Alternative Payment Models (APMs).

We’ll cover both of those options in detail in this MACRA series, starting with this post on MIPS.

(Click here to get our series of MACRA-related analysis articles delivered right to your inbox.)

CMS projects between 592,000 and 642,000 physicians will submit data to MIPS in 2017. If you are considering the MIPS option of MACRA, this article highlights the most important information and considerations for your practice.

How is MIPS Different Than Existing Quality Reporting and Payment Programs?

Well, there is some disagreement on that point. In many ways, it is the same--the Quality Payment Program (QPP) requires reporting similar to that already in place for existing programs like the Physician Quality Reporting System (PQRS), Meaningful Use, and the Physician Value-Based Payment Modifier (VM).

CMS calls this “streamlining”, meaning that all of these programs are now part of a single larger program. It may be streamlined from a government perspective, but it still requires collection and reporting of multiple categories of quality metrics, which doesn’t result in “less work” for clinicians.

In other ways, it is quite different--adding a new reporting category and using consolidated scoring across categories of reporting to determine a single score affecting Medicare Part B payments. And unless you choose the Advanced APM route, unlike existing Quality Reporting programs, you CANNOT opt out.

Physician Participation under MIPS

MIPS allows clinicians to earn a performance-based payment adjustment for Medicare billings. Remember from our first article in this MACRA series that eligible clinicians are those with Medicare Part B billings of more than $30,000 annually and those seeing more than 100 Medicare patients per year.

An eligible clinician is identified as a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist
Note: Clinicians who enroll in Medicare for the first time in 2017 are exempt from reporting on measures and activities for MIPS until the following performance year.

CMS projects that 90% of eligible clinicians will choose the MIPS option for MACRA.

Performance Criteria for Reimbursement

In 2017, Medicare Part B reimbursement will be based on performance in three categories*:

  1. Quality
  2. Improvement Activities
  3. Advancing Care Information

*Starting in 2018, there will be an additional category—Cost.

Clinicians provide data to the Quality Payment Program (QPP) in the above categories. Based on a clinician’s (or their group’s) performance, he or she is eligible for a negative, neutral, or positive performance-based payment adjustment.

Category 1: Quality

This category replaces the Physician Quality Reporting System (PQRS). Participants (excluding groups using the web interface) will select up to 6 quality measures, including an outcome measure, for reporting of at least 90 days in 2017. (Click here to see the available quality measures.)

Groups using the web interface are required to report up to 15 quality measures for the full year.

Note: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted.

Category 2: Clinical Improvement Activities

This is a new category. Most participants must verify they have completed at least 4 improvement activities for a minimum of 90 days. Examples of these activities to advance practices would be care coordination and safety checklists. (Click here to see the available Clinical Improvement Activities measures.)

For rural or health professional shortage areas or groups of fewer than 15 participants, the requirement is only 2 improvement activities for a minimum of 90 days.

Category 3: Advancing Care Information

This category replaces the Medicare EHR Incentive Program, also known as Meaningful Use. It is also the only category that comes with a bonus option.

Participants are required to report on these 5 measures** for a minimum of 90 days:

  • Security Risk Analysis
  • e-Prescribing
  • Provide Patient Access
  • Send Summary of Care
  • Request/Accept Summary of Care

Bonus option #1: Submit up to 9 measures for a minimum of 90 days for additional credit. (Click here to see the available Advancing Care Information measures.)

Bonus option #2: Report Public Health and Clinical Data Registry Measures and use Certified EHR technology to complete certain activities in the Improvement Activities Category.

**If these measures do not apply to you, you may not have to submit this information.

Category 4: Cost (begins in 2018)

This category replaces the Physician Value-Based Payment Modifier (VM), but will not be factored into the MIPS score for 2017.

Reporting Options for 2017

Because 2017 is considered a transitional year for MACRA, eligible clinicians who choose the MIPS track have four reporting options. Depending on the data you choose to submit, your 2019 Medicare payments will be adjusted up, down, or remain neutral.

Option #1: Don’t submit any data for 2017.

This automatically results in a negative 4% payment adjustment in 2019.

Option #2: Submit some information on one quality category for 2017.

This “testing of the waters” option means you avoid a negative payment adjustment for 2019.

Option #3: Submit at least 90 days of data for 2017.

This requires submission of full data beginning no later than October 2, 2017 to meet the requirement. Participants in this option may earn a neutral or small positive payment adjustment for 2019.

Option #4: Submit a full year of data for 2017.

Complying with the full program during this transitional year may result in a moderate positive payment adjustment in 2019.

**For all reporting options, data is due on March 31, 2018**

Curious what future potential adjustments look like with MIPS? This is how the program impacts your Medicare reimbursement over time.

  • 2019: +/- 4% payment adjustment
  • 2020: +/- 5% payment adjustment
  • 2021: +/- 7% payment adjustment
  • 2022: +/- 9% payment adjustment

Are You Ready to Participate in MIPS?

Tracking of data is vital for success in this program, no matter which reporting option you choose.

Find out if your electronic health record system is certified by the Office of the National Coordinator for Health Information Technology by clicking here. You can search by developer, product name, or ACB/CHPL ID.

If your system is on the list, then you are ready to track data for MIPS.

Are You Among the Estimated 90% of Eligible Clinicians Opting for MIPS?

If so, then you are at a decision point for your level of participation (and future reimbursement rates) for 2017. The attorneys at Nixon Law Group can help you navigate this new change to maximize your eligible reimbursement rates and minimize the growing pains to comply with the final MACRA ruling.

Click here to connect with one of our experienced attorneys for help navigating the changes to Medicare reimbursement at your practice.

What Are Your Other Options?

In the next post in this series, you’ll discover what the Advanced Alternative Payment Models (Advanced APM) track in the final MACRA ruling includes so you can decide if this is a better option for your practice than MIPS. Be sure to subscribe to our email updates for the latest on MACRA and other healthcare regulation news.