The Medicare Access and CHIP Reauthorization Act (MACRA) has been finalized and will affect all providers that care for at least 100 Medicare patients or bill more than $30,000 a year. The new legislation repeals the existing fee-for-service payment structure and replaces it with a pay-for-performance program built on measures of quality and efficiency. It establishes two tracks for healthcare reimbursement, Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM). MACRA also combines three existing quality reporting programs into one new system and includes an additional program into MIPS. Healthcare providers will be rewarded or penalized based on their performance.


1. When does MACRA begin?

The program begins January 1, 2017 but providers who are not ready yet can begin collecting performance data anytime between January 1, 2017 and October 2, 2017. Regardless, the start date, performance data is due by March 31, 2018. Data collected in the first year will determine payment adjustments beginning January 1, 2019.


2. What are the options for provider participation?

The final rule includes two options for provider participation: Merit-Based Incentive Payment System (MIPS), and the Advanced Alternative Payment Model (APM).


3. What is Merit-Based Incentive Payment System (MIPS)?

The Merit-Based Incentive Payment System (MIPS) is a program that determines Medicare payment adjustments. It is composed of four categories contributing to an annual MIPS final score of up to 100 points:

  • Quality (Physician Quality Reporting System): 60% for 2017

Most participants must report up to 6 quality measures, including an outcome measure, for a minimum of 90 days. Groups using the web interface must report 15 quality measures for a full year.

  • Advancing Care Information (ACI, renamed from Meaningful Use): 25% for 2017)

Participants must meet the following requirements for a minimum of 90 days:

  • Security risk analysis
  • e-Prescribing
  • Provide patient access
  • Send summary of care
  • Request/Accept summary of care
  • Choose to submit up to 9 measures for a minimum of 90 days for additional credit
  • Clinical practice improvement activities (New category): 15% for 2017

Most participants must attest to having completed up to 4 improvement activities for a minimum of 90 days. Groups with fewer than 15 participants or participants in a rural or health professional shortage area must attest to having completed up to 2 activities for a minimum of 90 days.

  • Cost (value-based modifier), will be weighted for 2018: 0% for 2017

Calculated from adjudicated claims and will be weighted for 2018.

The final score earned by the provider for a given performance year determines MIPS payment adjustments. Annual final scores for each clinician are released to the public by CMS.


4. What is an Advanced Alternative Payment Model (APM)?

To qualify as an Advanced Alternative Payment Model (APMS), a participant must use Certified EHR Technology, report quality measures comparable to measures under MIPS, and be either: (1) a Medical Home Model expanded under CMS Innovation Center authority, or (2) require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses. Those providers who are eligible may be qualified for:

  • Annual 5% lump-sum bonus payments from 2019 through 2024
  • Beginning in 2026, higher annual premiums (for some participating providers)
  • Increased flexibility through physician-focused payment models


5. What happens to providers that choose not to participate in MACRA?

If providers fail to send their data, they will receive a negative 4% payment adjustment in 2019. The penalty increases each year to 5% in 2020, 7% in 2021, and 9% in 2022.


6. How does the final rule affect small practices?

CMS has reduced the time and cost to participate, increased the availability of Advanced APMs to small practices, and are providing $20 million a year in outreach and technical support to small practices over the next five years.


7. How will Medicare payments be adjusted and what can providers expect?

Depending on which Quality Payment Program a provider chooses and the data submitted, 2019 Medicare payments will be adjusted up, down, or not at all.

Below are the options:

  • Don’t Participate: If a provider fails to send in any 2017 data, they will receive a negative 4% payment adjustment.
  • Submit Something = Test: If a provider submits the minimum amount of data to Medicare (for example, one quality measure or one improvement activity), they can avoid a downward payment adjustment.
  • Submit a Partial Year = Partial: If a provider submits 90 days of 2017 data to Medicare, they may earn a neutral or small positive payment adjustment.
  • Submit a Full-Year: If a provider submits a full-year of 2017 data to Medicare, they may earn a moderate positive payment adjustment.

The size of the payment adjustment depends on how much data is submitted and the quality results.

Laurie Zabel, CHC, CPC
Laurie Zabel, CHC, CPC is Director of Coding & Compliance for MedSafe. She is a healthcare professional who has over 25 years of Practice Management and Compliance experience. Laurie is a Certified Professional Coder (CPC), a physician chart auditor, a certified ICD-10-CM/PCS Trainer, and is certified in Healthcare Compliance (CHC). Prior to joining MedSafe, Laurie worked for a large University-Academic Medical Center in New Jersey where she was the Practice Manager for the Department of Obstetrics, Gynecology, and Reproductive Sciences. Her experience there included operations management, EMR implementation, policy & procedure development, accounts receivable management, and ensuring staff compliance with OSHA, HIPAA, and EOHSS.


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