Becoming MACRA Compliant: This is What Physician Practices Face

This story is published in concert with the Dallas County Medical Society, which produced the content. It’s an ongoing resource guide to making your practice complaint with MACRA. Enjoy. 

In November, the Centers for Medicare and Medicaid Services will pass a final rule regarding how physician practices will need to shift to become compliant with a new quality-based reimbursement program.

These proposed changes, which the Centers for Medicare and Medicaid Services has named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows physicians to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Step 1

Learn about MACRA and decide if an Alternative Payment Model is right for your practice.

If not, you’ll be paid fee-for-service with incentives or penalties under the new MIPS program. MACRA creates two payment pathways for physicians — APMs and MIPS. In 2017, most physicians will fall under MIPS. For the first performance period, MIPS will apply to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, which CMS collectively refers to as “eligible clinicians.”

As you learn about MIPS requirements, determine if you will report individually or as a group. CMS proposes to exempt physicians from MIPS in 2017 if they are in their first year of Medicare Part B participation, are part of an APM, or are below the low volume threshold of $10,000 in Medicare charges and 100 or fewer Part B-enrolled Medicare beneficiaries annually. These criteria may change in the final rules.

If you are part of the nonexempt majority, determine the impact to your practice and bottom line of a 4-percent bonus or penalty to your Medicare payment in 2019. As you learn about MIPS requirements, consider your potential practice costs and effort to comply with each MIPS category in 2017. For some practices, taking the penalty may be less costly than meeting the compliance and reporting requirements.

If MIPS compliance and reporting is right for your practice, consider the four weighted categories that comprise the performance measurement:

  • Quality (50 percent)
  • Advancing care information (25 percent)
  • Resource use (10 percent)
  • Clinical practice improvement activity (15 percent)

In 2017, the weighted performance category scores will be added to create a composite performance score from 0 to 100. Your weighted score will determine whether you receive a Medicare payment bonus, penalty or neither in 2019. If you plan to transition to a new group practice, your future pay may be affected by your new group’s past performance. This is because CMS proposes to define a group in 2017 as consisting of a single tax identification number (TIN) with two or more eligible clinicians (as identified by their individual National Provider Identifier) who have reassigned their billing rights to the TIN.

Because payment for any year is determined by the performance period two years previously, you should ask about the group’s past MIPS performance. You may be subject to the new group’s 2019 MIPS incentive or penalty based on how it performed in 2017. If you leave a group during 2017 and the group participated in MIPS that year, consider how the group could address retrospective compensation/incentive in your employment agreement, depending on its 2019 MIPS incentive or penalty.

Step 2

Assess your performance under Medicare’s current quality programs.

MIPS replaces and will include concepts from the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and Electronic Health Record (EHR) Incentive Program (meaningful use). The transition to MIPS may be easier if you are familiar with current CMS quality programs. Assess your performance under these programs and, as you learn about MIPS requirements, determine the changes you’ll have to make in your practice to meet the requirements for each MIPS category.

The Quality category will be similar to PQRS; however, CMS proposes to score you on up to three population-based measures calculated from administrative claims in addition to the number of quality measures you are required to report. The Advancing Care Information category will replace the meaningful use program. The Resource Use category will be similar to the VM program.

CMS proposes to calculate and score Resource Use measures using administrative claims data only. If you participate in the PQRS and VM programs, and you haven’t reviewed your reports, learn the type of feedback CMS provides and the data it uses to assess your quality and cost performance. For the PQRS program, access your PQRS feedback report; for the VM program, access your Quality and Resource Use report (QRUR).

Analyzing your feedback reports will help you prepare for the Quality and Resource Use categories in MIPS. Consider which practice strategies would optimize performance and improve your scores in 2017. Past reports are available at any time on the QRUR section of the CMS website; reports for the 2015 PQRS and VM performance period are expected to be released this month. If you’re new to the current quality programs and would like to participate in them in 2016, visit TMA’s resource centers to learn how to get started and the TMF Quality Innovation Network for free education, quality consulting and technical assistance.

Step 3

Review MIPS quality measures and reporting mechanisms.

You can report data on quality measures for MIPS in the same way you have reported data to PQRS. However, CMS has proposed to change some reporting requirements, which may include increased reporting thresholds and all-payer data for certain reporting mechanisms. To prepare for the Quality category, review the list of proposed quality measures in the MACRA proposed rule. Visit www. for the list of proposed individual quality measures available for MIPS reporting in 2017, specialty measures set, and proposed individual quality cross-cutting measures.

In the proposed rule, physicians and groups will have to select their measures from the list of all MIPS individual measures or from a specialty-specifi c measure set. Determine which reporting mechanism will best fi t your practice in 2017. Start by reviewing the existing reporting methods under the PQRS program: Medicare Part B claims, registry, qualifi ed clinical data registry (QCDR), EHR, web-interface (for groups with 25 or more healthcare providers), and Consumer Assessment of Healthcare Providers and Systems surveys.

After CMS publishes the final list of MIPS quality measures and reporting requirements (scheduled for Fall 2016), review the data completeness criteria for each reporting mechanism, select your measures and review each measure’s benchmark, specifications and documentation requirements. In selecting measures to report, keep in mind that simply reporting data on quality measures will not be sufficient to earn a high score.

Reporting is necessary, but your score is controlled by how well you perform on each quality measure. Prepare your practice for audits. CMS has proposed selectively auditing physicians and other eligible clinicians annually to conduct “data validation and auditing” of any data submitted under MIPS. Review your documentation and ensure that EHR templates are used with care, and that data fields in EHR and/or paper charts clearly capture the documentation required to support each measure. Keep a record of which patients you report on per measure and performance period so you can identify medical records easily if you are selected for an audit.

Step 4

Contact your EHR vendor.

The Advancing Care Information (ACI) category of MIPS replaces the current meaningful use program. Ask your EHR vendor about its MIPS readiness plan and how the vendor can help you be successful in MIPS. To meet the requirements of the ACI category, an EHR is required. Check with your EHR vendor to ensure the product you use will be upgraded to meet the metrics required. As vendors upgrade, the product must be certified by a government Authorized Certification Body. The next upgrade will be to the 2015 certification criteria, which is optional in 2017 and required in 2018.

Review the current meaningful use metrics. Although the final rule will diff er slightly, the current measures are a good place to learn about what is expected. Make sure you conduct an annual security risk analysis. HIPAA auditors or consultants, can provide this, including DCMS Circle of Friends member DKB Innovative. Also, talk to your vendor about public health reporting options.

Step 5

Explore the list of Clinical Practice Improvement Activities.

The CPIA category is a new performance requirement. In 2017, all physicians and groups must engage in or implement a number of activities to receive credit for the CPIA category in MIPS. In the MACRA law, CPIA subcategories include expanded access, population management, care coordination, patient engagement, patient safety and practice assessment, and transition to or participation in an APM. CMS has proposed three additional subcategories: achieving health equity, emergency preparedness and response, and integrated behavioral and mental health.

Physicians who participate in a nationally recognized, accredited patient-centered medical home will receive full CPIA credit. The required number of CPIAs will vary from one to six depending on the weighting of each CPIA and your practice model, size and location. Performance of activities in each subcategory is not required in order to receive the highest possible score.

CMS has proposed that each CPIA be performed for at least 90 days during the performance period. Note the weighting of each CPIA. CMS has proposed about 94 CPIAs and may add more when the rule is finalized in November. Identify CPIAs your practice already does and will continue in 2017, and which activities your practice could implement to receive credit for the first performance period. If you don’t now engage in any activity on the list, identify CPIAs that fit your practice, and prepare to engage in or implement them in time for the first performance period.

To report your CPIAs for MIPS credit, CMS has proposed several data submission mechanisms: qualified registry, QCDR, EHR, health IT vendor, attestation, and/or administrative claims. Once the final rule is published, review all requirements and submission mechanisms, select your activities from the complete CPIA inventory, and prepare to engage in or implement CPIAs according to the requirements. Make sure you have documented policies and procedures in place to document CPIAs you already are doing or plan to do in the future.


Posted in Government/Law, News, Physicians.