One intent of healthcare reform is an improvement in the quality and efficiency of care. Much of the attention of practitioners, administrators, and executives has been on the provisions of the Affordable Care Act. But that isn’t the only regulation and legislation affecting the industry.
Another has been the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. As the Centers for Medicare and Medicaid Services (CMS) explained, there had previously been the “Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years.”
Under MACRA, CMS had released a proposed rule establishing a new Quality Payment Program including the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Those affected were those practitioners falling under Medicare Part B, which means physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that employ such people. The practitioners must provide care for more than 100 Medicare patients and who bill Medicare at least $30,000 annually. The final rule is the one that will be put into use.
MIPS consolidates three different quality improvement systems under one. There can be significant improvements in pay under MIPS, or a drop of as much as four percent or no change. It all depends on the amount of quality data providers send to CMS in 2017. Send none and you lose money. The more you send, the better the increase. There is also additional potential payments for “exceptional” performance. Practitioners will have to report on six different quality measures or, instead, a set of measurements tailored to a particular specialty. They will have to complete either four medium-weighted or two high-weighted practice improvement activities. There will be reporting on five EHR-related measures, rather than the original 11.
Under APMs, eligible practitioners can potentially qualify and gain incentives. The proposed requirements for eligibility includes use of electronic healthcare records, quality measure-based payments, and having more than “nominal risk” for losses. Under the final rule, the risk must be at least eight percent of all Medicare reimbursements or three percent of expenditures the practitioner is responsible for under the APM. Some APMs will not count as Advanced APMs, which means the practitioners will be under a MIPS track.
This is a complicated and important area for many practice groups that have a significant Medicare practice. Administrators and managers will need to understand the specific requirements to ensure that reimbursement doesn’t suddenly drop and that, instead, they manage to court some of the many incentive payments available.
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