The FINAL MACRA RULE relaxed the more stringent proposed requirements for 2017, so whether you choose to dip your toe in the water or take the full-on reporting plunge, NOW is the time to get MACRA-ready and avoid reimbursement penalties in 2019.

Have you finished reading the 2400-page Final MACRA Rule yet regarding Medicare reimbursement and reporting?

Don’t worry; we read it for you.

The big takeaway is that if you have Medicare Part B billings of more than $30,000 per year and see over 100 Medicare patients annually, you are impacted by MACRA.

If that’s you, we’ve got the high points for you to know now, and over the coming weeks, we’ll share more about the components of MACRA that will impact your Medicare practice in 2017 and beyond.

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

What is MACRA?

The Medicare Access and CHIP Reauthorization Act (MACRA) is redefining how physicians get paid for caring for Medicare patients.

The Centers for Medicare & Medicaid Services (CMS) released the proposed rule on MACRA in April and finalized it in October. This rule replaces the old Sustainable Growth Rate (SGR) formula and is an effort to move away from the current fee-for-service model and toward a value-based payment system. In addition, it consolidates the existing quality reporting and payment programs--(1) The Physician Quality Reporting System (PQRS), (2) Meaningful Use, and (3) the Physician Value-Based Payment Modifier (VM)--into a single Quality Payment Program or "QPP."

The American Medical Association had this to say about the final rule: “With the flawed Sustainable Growth Rate (SGR) formula – and its annual threat of steep payment cuts – permanently eliminated, the new law gives many physicians the opportunity to be rewarded for the improvements they make to their practices and for delivering high-quality, high-value care to Medicare patients."

But we've spoken with physicians, and neither we nor they believe it’s all that simple.

MACRA does provide significant opportunities for Medicare providers, but it also imposes significant burdens, especially for those providers who are just starting the transition to quality reporting and value-based reimbursement. We are going to spend the next few months providing you with as much information as we can to help you understand what you need to do to seize these opportunities and navigate the new requirements.

(Be sure to subscribe to our twice-monthly updates so you don’t miss any of our MACRA analysis or other changes and advances in health care law.)

There are now two reimbursement tracks for physicians treating Medicare patients. The first is called the Merit-based Incentive Payment System ("MIPS"), and the second is referred to as the Advanced Alternative Payment Model ("APM") track. We’ll tell you more about each option in our upcoming posts. 


CMS intends 2017 to be a transition year for MACRA. Most providers will fall into the MIPS track. In the Final Rule, CMS has relaxed the full-year MIPS reporting requirements, instead providing four reporting options to accommodate an easier transition to the new MACRA requirements:

Option 1: Test with Partial Data to Avoid a Downward Adjustment

Test the Quality Payment Program by submitting some data (for instance, track one improvement activity or one quality measure) via MIPS. By doing this, physicians avoid a downward payment adjustment. The requirement is that you start collecting this data no later than October 2, 2017.

Option 2: Comply for 90 Days to Earn a Neutral or Small Adjustment

Participate in the program by reporting quality measures via MIPS for at least 90 days of 2017. As above, you must start no later than October 2, 2017. If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small payment adjustment.

Option 3: Participate for a full year to be eligible for a Moderate Positive Adjustment

Participate for the entire year and submit your full year of 2017 data to Medicare may result in a moderate positive payment adjustment. You must start data collection on January 1, 2017 and report for the full year via MIPS.

Option 4: Do nothing

Forget about testing the waters and don't report any quality measures at all.  The result will be a negative reimbursement adjustment of 4% in 2019.  In our view, this is the least desirable choice, since many physicians already have the capacity to track and report at least some quality measures. And penalties for not participating in MIPS only increase over the next several years, so the time to start is now.

Participate in an Advanced Alternative Payment Model to be Eligible for a 5% Bonus

As an alternative to MIPS, physicians may choose to participate in an Advanced Alternative Payment Model in 2017.  This choice can result in a 5% lump sum incentive payment.


Physicians who choose this option are exempt from the MIPS reporting. Per the Final Rule, Advanced APMs include:

  • Comprehensive ESRD Care (CEC) - Two-Sided Risk;

  • Comprehensive Primary Care Plus (CPC+),

  • Next Generation ACO Model, Shared Savings Program - Track 2,

  • Shared Savings Program - Track 3,

  • Oncology Care Model (OCM) - Two-Sided Risk.

For all options, 2017 data must be submitted by March 31, 2018.

Small Practice Considerations

As stated above, MACRA only applies to physicians billing in excess of $30,000 per year to Medicare or seeing more than 100 Medicare patients annually.

To ease the burden on small practices, rural areas, and areas with a shortage of health professionals who still meet the MACRA threshold, CMS has committed to providing $100 million in technical assistance to physicians participating in MIPS.

Industry Reaction to the MACRA Rule

Acting CMS Administrator Andy Slavitt told reporters in a conference call that the thousands of comments received on the proposed rule could be summarized as: "Make the transition to MACRA as simple and as flexible as possible."

Reaction to the final MACRA rule has generally been optimistic, as physicians and industry groups felt that CMS gave proper consideration to their comments and concerns during the feedback period.

“It's a return to the original intent, which was that future stages and the final stage of the health IT incentive program be about outcomes,” said former ONC Chief and current Aledade CEO Farzad Mostashari. “And it's not so much compliance with a bunch of check-the-box exercises, but using technology to achieve delivery and payment reform goals. The rule takes us a little bit closer to that vision.”

In the next post in this series, we’ll cover MIPS options in detail. CMS projects between 592,000 and 642,000 physicians will submit data to MIPS in 2017. If you are one of those physicians, be sure to subscribe to our email updates for the latest.

What does MACRA Mean for Your Practice?

That’s a question we can help you answer. From determining your eligibility in the program to picking your pace toward compliance in 2017, the attorneys at Nixon Law Group can help.

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

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