Making Sense of MACRA: The AAFP's Top 10 Frequently Asked Questions

Fam Pract Manag. 2018;25(5):9-12. 

1. How do I find out if I am required to participate in the Quality Payment Program (QPP)?

Eligible clinicians (ECs) for the 2018 performance period include medical doctors, doctors of osteopathy, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse anesthetists.

Eligible clinicians can verify their eligibility status in the QPP by entering their national provider identifier (NPI) number in the QPP Participation Status Tool at www.qpp.cms.gov/participation-lookup. The tool provides eligibility status for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (AAPM) qualifying participant status.

A clinician may be excluded from MIPS if they:

  • Provided care to less than 200 Medicare Part B beneficiaries or received less than $90,000 in Medicare Part B payments (referred to as the low-volume threshold); or

  • Are in their first year of Medicare participation; or

  • Qualify for the AAPM bonus.

The Centers for Medicare & Medicaid Services (CMS) will calculate an EC's low-volume threshold status by using two sets of claims data. For the 2018 performance period, the first data set will include claims data from September 1, 2016, to August 31, 2017. The second data set will include claims data from September 1, 2017, to August 31, 2018. ECs who fall below the low-volume threshold in either determination period are excluded from MIPS for the performance period. An EC will receive a low-volume threshold determination for each tax identification number (TIN) where the EC practiced during the performance period.

2. Do I need to register to report?

No. Registration is only required for those wishing to report using the CMS Web Interface or those using Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS. Groups that registered to use the CMS Web Interface for the 2017 performance period do not need to re-register. However, cancelations or changes to a group's registration needed to be made before the registration deadline of June 30, 2018.

3. What are the requirements for reporting as an individual versus reporting as a group (defined by tax identification number [TIN])?

INDIVIDUAL GROUP (TIN)
Each NPI is reported individually All NPIs are reported together
Each individual selects measures to report All clinicians must report the same measures
Each category reported as an individual Each category reported as a group
Low-volume exclusion determined at the NPI level
  • Low-volume exclusion determined at the group level

  • An EC excluded as an individual (based on low-volume threshold) would be included in group reporting and receive a MIPS final score and payment adjustment based on the group's performance

Data collected at the individual level
  • Includes data from all ECs within the tax identification number (TIN)

  • Clinicians excluded from MIPS based on provider type or because they are newly-enrolled in Medicare will not receive a MIPS final score or payment adjustment. ECs excluded based on the low-volume threshold will receive a MIPS payment adjustment.

Final scores determined at the NPI level
  • Each NPI receives the same final score based on the group's performance

4. Does MIPS apply to employed physicians?

Yes. While most employed physicians will report as part of a group, MIPS payment adjustments are applied at the NPI level. If an employed physician changes practices between the performance period and the payment year, the physician's MIPS score and accompanying payment adjustment will apply to Medicare Part B payments at the new practice.

When making hiring decisions, potential employers may take your MIPS final score into consideration. Additionally, employers may begin basing your compensation on your MIPS final score. Employed physicians will want to make sure they are appropriately compensated for a high MIPS score.

5. Is it too late for me to report for 2018 and how can I reach the threshold?

No. The MIPS performance threshold for the 2018 performance period is 15. An additional threshold for exceptional performance has been set at 70. Clinicians can meet the performance threshold is several ways.

Figure 1.

2018 Scoring Thresholds

Practices that attest to having patient-centered medical home (PCMH) certification will receive full credit in the improvement activities category, which accounts for 15 points toward the MIPS final score. At least 50% of the practices within the TIN must be a certified PCMH for an entire TIN to receive credit.

Certifying PCMH bodies include the National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), Accreditation Association for Ambulatory Care (AAAHC), URAC, or state-based, regional, private payers, or other entities that administer PCMH accreditation to at least 500 practices.

If they are not a PCMH, practices can attest to completing individual improvement activities. In general, practices must attest to completing two high-weighted (20 points each) activities, four medium-weighted (10 points each) activities, or a combination of both to achieve a total of 40 points. Activities are double-weighted for small practices (15 or fewer ECs) and rural or health professional shortage area (HPSA) practices. Practices in these settings can attest to one high-weighted activity or two medium-weighted activities to meet the improvement activities category requirements. For all practices, an activity must be performed for at least 90 consecutive days, giving practices until October 1, 2018, to implement an improvement activity or activities. A full list of activities can be found on the QPP website at www.qpp.cms.gov/mips/improvement-activities.

As part of CMS's efforts to reduce the burden for small practices, any quality measure submitted will receive three points. This means measures that do not meet the case minimum or data completeness threshold will still receive three points each. Small practices can report six measures for one patient, one time and receive 15 points towards their MIPS final score.

6. How long is the performance period?

For the 2018 reporting period, clinicians will be assessed on a full calendar year of data for the quality and cost performance categories. There is no data submission required for the cost category as CMS calculates these measures using claims data. The promoting interoperability (formerly called advancing care information) and improvement activities performance categories require 90 consecutive days of data. It does not have to be the same 90 days for both categories. The last day to begin collecting data for the promoting interoperability and improvement activities categories is October 1, 2018.

7. What happens if I change practices during the performance period?

If an EC bills under more than one TIN during the performance period, CMS will use the highest final score associated with the clinician's NPI number during the performance period to adjust payment in the payment year.

If a clinician changes TINs between the performance period and payment year, CMS will apply the final score associated with the clinician's NPI number during the performance period to the new TIN/NPI combination in the payment year. For example, if a clinician practiced at TIN A during the performance period, but is practicing at TIN B during the payment year, CMS will use the final score from TIN A to apply to the payment adjustment to the new TIN B. A clinician without a MIPS final score (due to exemption) will not have a payment adjustment associated with their NPI number. If this clinician changes practices between the performance period and payment year, no adjustment will be applied at the new practice.

8. How is cost being measured?

Cost accounts for 10% of the MIPS final score in 2018. Clinicians will be assessed on Total per Capita Cost and Medicare Spending per Beneficiary (MSPB). Cost measures are calculated by CMS using claims data. CMS is developing additional episode-based measures to be used in future program years.

Figure 2.

MIPS Category Weights

9. Are there any bonus points available? What has CMS done to help small practices?

For all practices, CMS will add up to five points to the MIPS final score based on patient complexity. The bonus is based on the practice's average hierarchical condition category (HCC) risk scores and the proportion of dual-eligible (having both Medicare and Medicaid) patients.

Small practices (15 or fewer ECs) that submit data for at least one performance category will automatically have five bonus points added to their MIPS final score.

Additional provisions to assist small practices include:

  • Increased low-volume threshold;

  • Double points for all improvement activities;

  • Quality measures that do not meet the case minimum or data completeness criteria receives three points; and

  • Small practices may apply for an exemption from the promoting interoperability performance category.

10. How will I receive feedback on my performance?

The Centers for Medicare & Medicaid Services will provide annual feedback to clinicians through the QPP Portal at www.qpp.cms.gov/login. MIPS feedback reports for the 2017 performance period were released in July. Additionally, most registries, EHRs, and qualified clinical data registries (QCDRs) can generate performance reports. These reports provide an opportunity to review your performance throughout the performance period and make any corrections or adjustments.

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