MACRA Participation Requirements for Primary Care

The regulations regarding the collection of performance data as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) came into effect in January 2017 and is of tremendous importance to primary care providers (PCPs) because it enacts revised methods of clinician reimbursement for the treatment of Medicare patients. This revised reimbursement model is the Quality Payment Program (QPP).

The focus of the MACRA QPP is to implement a payment model that moves away from the traditional itemized fee-for-service payment to a value-based payment model based on quality outcomes.

The CMS QPP website notes that, while participation is not mandatory, those who don't participate and submit data in 2017 will receive a 4% negative reimbursement adjustment in 2019 for treatment of Medicare patients. PCPs can avoid being penalized by participating in one of two pathways; either through the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM).

2017 is referred to as the QPP Transition Year, while 2018 is being referred to as QPP Year 2 and is the second year of preparation for QPP Year 3 and beyond.

Participation Pathways

Similar to the Transition Year of 2017, the 2018 Year 2 of the QPP provides two pathways for participation, MIPS and APM.

Eligible Clinicians

Primary care clinicians are considered to be eligible clinicians (ECs) for the purpose of MIPS participation which includes:

  • Medical doctor
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist

Participation Differences

There are a number of differences between the participation standards for 2017 and 2018. Here are some of the most prominent ones:

  • Volume Threshold Exclusions
    • Billing - From less than or equal to $30,000 of Medicare Part B Allowed Charges in 2017 to less than or equal to $90,000 in 2018.
    • Patients - From less than or equal to 100 Medicare Beneficiaries in 2017 to less than or equal to 200 in 2018.
  • Category Weighting
    • Quality - From 60% in 2017 to 50% in 2018
    • Cost - From 0% in 2017 to 10% in 2018
    • Improvement Activities - Stays the same at 15%
    • Advancing Care Information - Stays the same at 25%
  • Data Completion
    • 50% in 2017 increasing to 60% in 2018
  • Performance Period (to be eligible for an incentive payment)
    • 90 day minimum in 2017 for Quality, Advancing Care Information and Improvement Activities. Cost is figured by CMS for 12 month period.
    • No change in 2018 for Advancing Care Information, Improvement Activities and Cost. The performance period for Quality increases to a 12 month minimum.

There are also some new items in 2018 that were not available for 2017, including:

  • Bonuses
    • Complex Patient bonus - Up to five bonus points
    • Small Practice bonus - A five point bonus for practices with 15 or fewer ECs.
  • Virtual Group - Made up of solo practitioners or groups of 10 or fewer ECs who come together “virtually” - regardless of geographic location or specialty - to participate in MIPS for a one year performance period

What Now?

Time is rapidly coming to a close to avoid a 4% negative reimbursement adjustment in 2019. The CMS QPP website states, "If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment."

There is not much time left to prepare for the 2018 QPP Year 2 participation period. For more specific information click here to go to the CMS Quality Payment Program Year 2 website.

Concordance Healthcare Solutions has management products and services that can help track and improve your MACRA-related activities. Click here to contact us for more information.

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