Are you prepared to protect your Medicare reimbursement?


Is your practice prepared for MACRA (The Medicare Access and CHIP Reauthorization Act) and the potential reductions in Medicare reimbursement associated with the recently proposed rules?   Perhaps lost in the shuffle last year due to the implementation of ICD-10, was the creation of MACRA, which was signed into legislation by President Obama on April 16, 2015.  Fast forward one year later to current day and the recently proposed MACRA rules, which have been described as the most significant Medicare policy change in recent history.  Unless you are a new Medicare provider, bill a very low volume of Medicare claims, or associated with a Rural Health Clinic or Federally Qualified Health Center, your Medicare reimbursement is at risk – there is no opting out of this program.

MACRA replaces the sustainable growth rate (SGR) formula with a framework that rewards (or penalizes) providers for providing higher quality care through the creation of two reimbursement pathways:  Merit-based incentive Payment System (MIPS), and Alternative Payment Models (APMs).  Additionally, the proposed rules collapse three existing quality reporting programs (PQRS, Value-based Payment Modifier, and Meaningful Use) into the newly created MIPS pathway.  By all indications, the majority of providers will follow the MIPS pathway with only providers taking on a risk-based payment model following the APMs track.

Because most providers will follow the MIPS pathway, it is important tFeatures_DDAF_1. MACRA - MIPS score componentso understand the four components contributing to a MIPS score:


Based on these four categories, providers can earn a score ranging from 1 to 100, and then will be compared to a national statistic.  On November 1 of this year, CMS is scheduled to release its listing of quality reporting criteria which will include measures from existing programs as well as new and updated measures.  Each provider must then select the six criteria on which they choose to be evaluated.  The initial reporting and evaluation period is scheduled to start on January 1, 2017 with provider quality data impacting 2019 Medicare reimbursement – either positively or negatively.  Since MACRA was designed to maintain overall budget neutrality, there will only be winners and losers.  The following outlines the proposed Medicare Part B reimbursement impact relative to the MIPS pathway:

Features_DDAF_2. MACRA - percent rainbowTo be eligible for the APMs model, the provider’s participation in a qualifying APM will be reviewed by CMS.  To qualify for the APMS model, providers must get at least 25 percent of their Medicare Part B business (defined as patients or charges) through an advanced APM.  The percentage threshold for this pathway climbs from 25 percent in 2019 to 50 percent in 2021 and 75 percent in 2023.  In short, if providers are not already participating in an APM track, it may be difficult to keep pace with the thresholds and qualify for this track.  As CMS outlined in the proposed rules, roughly 30,000 to 90,000 providers will qualify for the APM track, as compared to approximately 700,000 participating in the MIPS track.  Based on the proposed rules, the APMs that satisfy MACRA criteria are:

  • Comprehensive ESRD Care (LDO Arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program: Track 2
  • Medicare Shared Savings Program: Track 3
  • Next Generation ACO Model
  • Oncology Care Model Two-Sided Risk Adjustment

Also of note, providers cannot participate in both reimbursement pathways – that means that providers eligible for an APM pathway will not be MIPS eligible and vice versa.

MACRA will change Medicare Part B reimbursement as we know it.  To help protect your Medicare Part B reimbursement from future penalties, now is the time to assess your readiness and implement operational changes that might be needed to potentially share in the positive reimbursement adjustments scheduled in 2019.  Remember, there will only be winners and losers – you must act now to increase your chances at improving your Medicare Part B reimbursement.

Features_DDAF_3. MACRA - Is your practice MACRA ready

-Adam Shewmaker and Porter Roberts are with Dean Dorton Allen Ford.