Overview
The Medicare Access and CHIP Reauthorization Act (MACRA) focuses on restructuring Medicare Part B payments for professional services by shifting from fee-for-service (FFS) “Volume” to Value-based reimbursements “Quality” This is being accomplished through:
Eligibility
Quality Payment Program Tracks
MIPS has effectively consolidated the Physician Quality Reporting System (PQRS), Value Based Payment Modifier (VM), and EHR Incentive Program (Meaningful Use) programs into one MIPS program that compares each Eligible Clinician’s (EC) performance against their peers. EC’s who outscore their counterparts will receive a positive MIPS Payment Adjustment, which will be offset by a negative MIPS Payment Adjustment to those EC’s with scores below the performance threshold.
Low-Volume Threshold Criteria – To be excluded from MIPS, clinicians or groups would need to meet one of the following three criteria:
Opt-in Policy *New*
Payment Adjustment
2018:
2019:
Scoring Threshold
2019 MIPS Threshold is 30 out of 100
Exceptional Performance Bonus Threshold = 75 Points
Category | Performance Period | Category Weight |
---|---|---|
Quality | 12 Months | 45% |
Promoting Interoperability | 90 Days | 25% |
Improvement Activities | 90 Days | 15% |
Cost | 12 Months | 15% |
Quality Weight: 45% (50% in 2018) Bonus Points Scoring Measures – Measures are scored based on the following: Submission – Ability to Submit Same Measure across multiple Collection Types Promoting Interoperability Weight: 25% (25% in 2018) Required: 2015 Edition Certified EHR Technology (CEHRT) New Performance-Based Scoring: Failure to report or claim an exclusion on any measure results in a zero for category Promoting Interoperability Objects & Measures Improvement Activities Weight: 15% (15% in 2018) Cost Weight: 15% (10% in 2018) 8 New Episode-Based Measures Complex Patient Bonus Bonus of up to 5 points to the overall Composite Performance Score (CPS) for complex patients based on the combination of:
Objectives Measures Max Points If Excluded, Reassigned to:
e-Prescribing e-Prescribing 10 Points Health Information Exchange
Query of Prescription Drug Monitoring Program (PDMP) (New) 5 Bonus Points
Verify Opioid Treatment Agreement (New) 5 Bonus Points
Health Information Exchange (HIE) Support Electronic Referral Loops by Sending Health Information (Send a Summary of Care) 20 Points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (New) 20 Points Support Electronic Referral Loops by Sending Health Information
Provider to Patient Exchange Provide Patients Electronic Access to their Health Information (Provide Patient Access) 40 Points
Public Health and Clinical Data Exchange Report to two of the following: 10 Points Provide Patients Electronic Access to their Health Information
• Immunization Registry Reporting
• Electronic Case Reporting
• Public Health Registry Reporting
• Clinical Data Registry Reporting
• Syndromic Surveillance Reporting
Security Risk Assessment Not considered an objective or measure but still an attestation requirement 0 Points
Measure Case Minimum Attribution
Total Per Capita Cost 20 Cases Plurality of primary care services
MSPB 35 Cases Plurality of Part B services billed during the index admission
Episode-Based Measures (NEW) Procedural = 10 Cases
Acute Inpatient Conditions = 20 CasesProcedural Episodes: Performing Clinician
Acute Inpatient Condition Episodes - Clinicians
who bill > 30% of evaluation and management during hospitalization
2019 Timeline
MIPS has a two-year time period from performance to payment adjustment:
Reporting Options
Individual:
Group:
Virtual:
Submission Type: The mechanism by which a submitter type submits data to CMS includes:
Submission Methods:
MIPS - Categories | MIPS Individual | MIPS Group |
---|---|---|
Quality | •Direct •Log-In and Upload •Medicare Part B Claims | •Direct •Log-in and Upload •CMS Web Interface •Medicare Part B Claims |
Promoting Interoperability | •Direct •Log-in and Upload •Log-in and Attest | •Direct •Log-in and Upload •Log-in and Attest |
Improvement Activities | •Direct •Log-in and Upload •Log-in and Attest | •Direct •Log-in and Upload •Log-in and Attest |
Cost | N/A CMS Calculates | N/A CMS Calculates |
CMS calculates the MIPS Composite Performance Score by adding each individual category score after it has been multiplied by its category weight.
Quality
Promoting Interoperability
Improvement Activities
Cost
Achievement Points/Available Points = Cost Performance Category Percent Score
MIPS Composite Performance Score
An Alternative Payment Model (APM) is a payment approach that gives incentive payments for providing high-quality and cost-efficient care. Certain APMs include Merit-Based Incentive Payment System (MIPS) eligible clinicians as participants. These types of APMs are called MIPS APMs, and participants receive special MIPS scoring under the APM scoring standard including:
2019 MIPS APM List:
*Note* Information within this section pertains to Medicare Shared Savings Program participants
APM Participation List:
Eligible Clinicians must be on the APM Entity’s Participation List at one of the three “snapshot” dates to be scored under the APM scoring standard:
If an eligible clinician joined a full TIN APM (Medicare Shared Savings Program), CMS will use a fourth “snapshot” date (December 31st) to determine APM Participation.
Low-Volume Threshold:
To be excluded from MIPS, the APM Entity (ACO) would need to meet one of the following three criteria:
Payment Adjustment
2018:
2019:
Scoring Threshold
2019 MIPS Threshold is 30 out of 100
Exceptional Performance Bonus Threshold = 75 Points
Category | Performance Period | Category Weight |
---|---|---|
Quality | 12 Months | 50% |
Promoting Interoperability | 12 Months | 30% |
Improvement Activities | 12 Months | 20% |
Cost | N/A | 0% |
Quality Weight: 50% (50% in 2018) Retiring: Additions: Promoting Interoperability Weight: 30% (30% in 2018) Required: 2015 Edition Certified EHR Technology (CEHRT) New Performance-Based Scoring: Failure to report or claim an exclusion on any measure results in a zero for category Promoting Interoperability Objects & Measures Improvement Activities Weight: 20% (20% in 2018) Retained: Cost Weight: 0% (0% in 2018) Retained: Complex Patient Bonus Bonus of up to 5 points to the overall Composite Performance Score (CPS) for complex patients based on the combination of:
ACO–12 (NQF #0097) Medication Reconciliation Post-Discharge
Objectives Measures Max Points If Excluded, Reassigned to:
e-Prescribing e-Prescribing 10 Points Health Information Exchange
Query of Prescription Drug Monitoring Program (PDMP) (New) 5 Bonus Points
Verify Opioid Treatment Agreement (New) 5 Bonus Points
Health Information Exchange (HIE) Support Electronic Referral Loops by Sending Health Information (Send a Summary of Care) 20 Points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (New) 20 Points Support Electronic Referral Loops by Sending Health Information
Provider to Patient Exchange Provide Patients Electronic Access to their Health Information (Provide Patient Access) 40 Points
Public Health and Clinical Data Exchange Report to two of the following: 10 Points Provide Patients Electronic Access to their Health Information
• Immunization Registry Reporting
• Electronic Case Reporting
• Public Health Registry Reporting
• Clinical Data Registry Reporting
• Syndromic Surveillance Reporting
Security Risk Assessment Not considered an objective or measure but still an attestation requirement 0 Points
2019 Timeline
MIPS has a two-year time period from performance to payment adjustment:
Submission Methods:
Performance Category | Reporting Requirement | Data Submission Mechanism(s) |
---|---|---|
Quality | ACO submits measures on behalf of their participating clinicians. | CMS Web Interface |
Promoting Interoperability | All ACO participant TINs submit according to the MIPS group reporting requirements. | • Direct • Log-in and Upload • Log-in and Attest |
Improvement Activities | None. Full credit awarded. | N/A |
Cost | None. Direct alignment with APMs goals. | N/A |
Advanced Alternative Payment Models (A-APMs) are a track of the Quality Payment Program that offers incentives for achieving certain Payment Amount or Patient Count thresholds. They are a subset of APMs that meet the following:
2019 Advanced APM List:
Based on the eligible clinician’s payment amount OR patient count threshold they are classified as:
Eligible Clinician Participation Requirements
Eligible Clinician Status | % of Payments | % of Patients | % of Payments - Min | % of Patients - Min |
---|---|---|---|---|
Qualified Participant | 50% | 35% | 25% | 20% |
Partial Qualified Participant | 40% | 25% | 20% | 10% |
*Based on Medicare payment/patient percentage through participating A-APM*
All-Payer Advanced Alternative Payment Models Option
Beginning in 2019, the Advanced APM path provides 2 ways for eligible clinicians to become QPs:
To determine eligible clinician participation status, CMS considers the Medicare APMs first, then, looks to see if the Medicare minimum thresholds are met before considering Other Payer APMs. If the Medicare minimum thresholds of the Medicare APM are not met, eligible clinicians cannot qualify as a Qualified Participants or Partial Qualified Participants. If the Medicare minimum threshold is met by either patient count or dollar amount, eligible clinicians can meet the Qualified Participant or Partial Qualified Participant status requirements with either option.
Other-Payer Advanced Alternative Payment Models
Other-Payer Advanced APMs are non-Medicare Fee For Service (FFS) payment arrangements with other payers including:
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