The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule was finalized on October 14, 2016 replacing the Sustainable Growth Rate by the new Quality Payment Program (Medicare Payment Reform).
Full rule and an executive summary can be found at the CMS Quality Payment Program page at www.qpp.cms.gov/education.
The Quality Payment Program has two paths: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs);
MIPS REPORTING CRITERIA:
1. Quality (formerly PQRS program): 30% – report up to 6 quality measures, include at least one outcome measures, for full calendar year at 70% completeness. See the See full measures specifications.
2. Promoting Interoperability (formerly known as Advancing Care Information, or Meaningful Use)”: 25% - meet the five required measures for a minimum of 90 days. Click here for detailed information.
3. Clinical practice improvement activities:15% – For groups less than 15 providers (but not individuals) , fulfill two medium-weighted improvement activities or one high improvement activity for a minimum of 90 consecutive days. For groups with 15 or more providers and individuals, fulfill any of the following: 4 medium-weighted improvement activities; or 1 high-weighted and 2 medium-weighted activities; or 2 high-weighted activities for a minimum of 90 consecutive days. Click here for detailed information.
4. Resource Use (based on claims data): 30% - For 2020, MIPS uses cost measures that cover the total cost of care during the year or during a hospital stay. Because we use Medicare claims data, we’ll calculate the Cost performance category score and you don’t have to submit any data. Please click here for more details.
Learn more about MIPS categories criteria and check your participation status.
Who will participate in MIPS (Eligible Clinician or EC)?
For year 1 and 2 (performance year 2017 and 2018 / payment adjustment year 2019 and 2020)
- Physicians (MD, DO, DDS)
- Physician Assistant (PA)
- Nurse Practitioner (NP)
- Certified Nurse Specialist (CNS)
- Certified Registered Nurse Anesthetics (CNRA)
For year 3+ onward (performance 2019 onward / payment adjustment year 2021 onward)
All of the above PLUS:
- Physical and Occupational Therapist
- Speech language Pathologist and audiologist
- Nurse Midwife
- Clinical social Worker and Clinical Psychologist
- Dietitian and Nutritionist
- Osteopathic Practitioner
Who will NOT participate in MIPS?
- Providers billing Medicare Part B for the first time or first year participation
- Providers qualifying for the low-volume exclusion: in a 12 month period, clinicians or groups each (a) bill $90,000 or less in Medicare Part B allowed charges for services; (b) provide care for 200 or fewer Part B beneficiaries; or (c) deliver 200 or fewer covered services to Part B beneficiaries. FOR 2020: Providers who exceed one or two (but not all three) of the low-volume thresholds can “opt-in” to MIPS! If they opt-in, they will receive a MIPS final score and a payment adjustment in 2021/2022.
- Qualified Professionals (QPs) participating in an Advanced APM
- Hospital and Facilities
- For performance year 2019, Medicare Part B payments for services are subject to MIPS payment adjustments. This excludes payments for items such as Part B drugs. Payments not subject to MIPS are Medicare Part A; Medicare Advantage Part C; Medicare Part D; CAH Method I facility payments; Federally qualified health center (FQHC), rural health clinic (RHC) ambulatory surgical center (ASC), home health agency (HHA), hospice, or hospital outpatient department (HOPD) facility payments billed under the facility’s all-inclusive payment methodology or prospective payment system methodology.
- The maximum negative payment adjustment for the 2020 performance period/2022 payment year is -9%. The actual adjustment is based on your MIPS final score from the 2020 performance period.
- You need 45 points to avoid a negative payment adjestment for the 2020 period/2022 payment year.
- For 2020, providers who exceed one or two (but not all three) of the low-volume thresholds can “opt-in” to MIPS. If they opt-in, they will receive a MIPS final score and a payment adjustment in 2022.
Click here for more information.