MACRA

The Medicare Access and CHIP Reauthorization Act (MACRA)

On January 1, 2017, implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 dramatically changed how licensed health care providers are paid by the Centers for Medicare and Medicaid Services (CMS). Signed into federal law by President Barack Obama on April 16, 2015, MACRA is a fix for the unsustainable Sustainable Growth Rate (SGR) formula.

To help streamline the implementation of MACRA, CMS publishes a final rule annually for the Quality Payment Program (QPP) to build a flexible system for eligible providers using multiple data submission pathways to connect quality to payments. Below are the permitted submission options for eligible providers, with each choice accompanied by a positive or negative payment adjustment. Please note that not all submission types are available for all performance categories:

Submission Type Description Available Performance Categories
Medicare Part B Claims Clinicians in small practices (reporting individually or as a group) can add Quality Data Codes (QDCs) to their claims to denote measure performance. Quality
CMS Web Interface Registered groups and their authorized representatives can report beneficiary level performance data in a secure, internet-based application. Quality
Log-in and Attest Groups and their authorized representatives can sign in to qpp.cms.gov and manually report Promoting Interoperability measures and/or Improvement Activities Improvement Activities, Promoting Interoperability
Log-in and Upload Groups, their authorized representatives, and third-party intermediaries can sign in to qpp.cms.gov and upload a file in a CMS approved format. Quality, Improvement Activities, Promoting Interoperability
Direct Authorized third-party intermediaries (such as QCDRs and Qualified Registries) can perform a direct submission, transmitting data through a computer-to-computer interaction, such as an API. Quality, Improvement Activities, Promoting Interoperability

*Table from CMS QPP “An Introduction to Group Participation in the MIPS in 2019”

The QPP data submission pathways seek to tie an increased percentage of physician’s Medicare fee-for-service (FFS) payments to outcomes via the Merit-based Incentive Payment System (MIPS) and encourage the adoption of “alternative payment models” (APMs). By adopting APMs, practices are required to take on more financial and technological risks. According to the MACRA legislation, participating providers will be able to switch between the MIPS and the APM track on a year-to-year basis, allowing further advancement of the U.S. healthcare system compared to what was in place over 20 years ago.

For more detailed information, please view the CMS QPP Resource Library.

Submit Data for the 2019 MIPS Performance Year

The 2019 performance year for the MIPS ends on December 31st, 2019. Eligible clinicians have until October 3rd, 2019 to begin the continuous 90-day performance period for Improvement Activities and Promoting Interoperability performance categories and submit data though MIPSwizard. The MIPSwizard submission deadline for the 2019 reporting year is March 31st, 2020.

*Graphic from CMS QPP “A Quick Start Guide to the Merit-based Incentive Payment System (MIPS): For 2019 Participation.”

Your score for the 2019 MIPS performance year is divided and weighted into four different categories:

  • Quality (45%)
  • Promoting Interoperability (25%)
  • Improvement Activities (15%)
  • Cost (15%)

Scores in each weighted category for the 2019 MIPS performance year will be calculated by first extrapolating the proportion of points earned from the total possible points in the weighted category which will then be multiplied by the performance category weight. This calculation will determine the total points earned.

*Graphic from CMS QPP “A Quick Start Guide to the Merit-based Incentive Payment System (MIPS): For 2019 Participation.”

MIPS participants who did not start their activities by October 3rd, 2019 are no longer eligible for a positive payment adjustment in 2021. However, MIPS-eligible clinicians can still avoid a 7% penalty by reporting data in two categories (Quality, Promoting Interoperability, or Improvement Activities) OR by reporting a combination of measures in different categories as long as they meet the 30-point minimum threshold. Using the latter methodology, clinicians have the option to report on any two quality measures.

Please use the following links to review specifics on any of the four weighted categories: Quality, Promoting Interoperability, Improvement Activities, Cost.