Medicare Access and Chip Reauthorization Act: Its Impact on Physician Compliance

Medicare Access and Chip Reauthorization Act: Its Impact on Physician Compliance

The Medicare Access and Chip Reauthorization Act (MACRA), which was signed into law in 2015, goes into effect in 2017. Physicians’ practices will need to make changes to become compliant with the new regulations surrounding the reimbursement program.

The changes, which the Centers for Medicare and Medicaid Services (CMS) have named the Quality Payment Program, will supplant the current reporting programs with a more flexible program. This will give physicians a choice between two payment methods designed to link quality care with payments: the Advanced Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS).

In order to stay compliant, practices will need learn more about MACRA and make a decision if one of the APMs is a reasonable fit. Without this selection, a physicians’ practice will be paid by fee-for-service with penalties or incentives under the MIPS program. It is estimated that most physicians will fall into the MIPS program. During the first period, MIPS will apply to eligible clinicians, which CMS defines as physicians, nurse practitioners, physician assistants, certified registered nurse anesthetists, and clinical nurse specialists.

While some physicians will be exempt from certain requirements, most will not. Those who are not exempt will need to analyze the costs versus benefits in complying with the four MIPS categories. In some cases, accepting a penalty may be less than the costs of meeting and staying compliant.

The four weighted categories in MIPS are:

  • Quality (50 percent)
  • Advancing care information (25 percent)
  • Resource use (10 percent)
  • Clinical practice improvement activity (15 percent)

The weighted category scores will be combined to determine a composite score from 0 to 100. This weighted score will be used to determine whether an eligible clinician receives a penalty, bonus or neither, beginning in 2019. In addition, CMS will begin to define a group as a single tax identification number, with two or more clinicians who have assigned their billing rights to the single TIN. Payment for future years will be determined by the performance from the previous two years. Therefore, a group’s performance should be analyzed prior to joining it.

Assessing Performance Under Current Medicare Quality Programs

MIPS supplants the Physician Quality Reporting Systems (PQRS), Electronic Health Record (EHR) Incentive Program, and the Value-Based Payment Modifier (VM), although certain concepts will be included from the replaced programs. Eligible clinicians should assess their performance under the current programs to determine the requirements for each MIPS category.

The quality category will almost identical to PQRS. Yet, CMS will also score on up to three measures that are population based. These will be calculated from administrative claims in addition to the quality measures. The Advancing Care Information category will supersede the meaningful use program, and the Resource Use category will be close to the VM category.

In addition, CMS will calculate Resource Use measures with data from administrative claims only. It will be critical for eligible clinicians to become familiar with these measures and the type of feedback that comes from CMS, including the data it uses to analyze cost and quality performance. Past reports are available on the CMs website.

Review MIPS Reporting Mechanisms and Quality Measures

CMS has proposed to make changes to some reporting requirements, which can include all payer data and higher reporting thresholds for some reporting mechanisms. In the proposed changes, eligible clinicians and groups will need to choose the measures from the MIPS lists or from a specialty-specific set of measures. Clinicians and groups will also need to review the specifications, benchmarks, and documentation requirements, and be aware that earning a high score will take more than reporting data on quality measures.

Reporting is required, but the score will be determined by the performance on each quality measure. Audits will be necessary, as CMS will be selectively auditing clinicians and groups on an annual basis. This is to ensure “data validation and auditing.” Keeping meticulous records is now a must.

Review EHR Requirements

Because the Advancing Care Information (ACI) category under MIPS supersedes the Meaningful Use program, EHR vendors should have a MIPS implementation strategy to stay compliant. Clinicians and groups should proactively seek out this information from their EHR vendor to ensure that the metrics remain up-to-date. The EHR products must receive certification from a regulatory authorized certification body. Certification will be required in 2018.

Clinical Practice Improvement Opportunities

The Clinical Practice Improvement Activities category is a new requirement. In 2017, all eligible clinicians and groups must implement certain activities to receive credit for that category under MIPS. Under the MACRA regulation, subcategories include population management, expanded access, patient engagement, care coordination, practice assessment, patient safety, and participation in or transition to APM. CMS has also proposed three more subcategories: emergency preparedness and response, health equity, and integrated behavioral and mental health.

Clinicians who participate in an accredited, nationally recognized patient-centered medical home will obtain full CPIA credit. The number of required CPIAs will depend upon the weight of each CPIA and the individual practice model, location and size. In addition, CMS has various requirements for the performance period.

With the extensive changes coming in 2017, it will be critical for eligible clinicians and clinician groups to become educated on every distinct aspect of the laws, in addition to having well-documented policies and procedures in place to ensure compliance.


Wendy Hoke is a successful writer with a background in the health and medical industry. She is deeply interested in staying abreast of and reporting on the latest issues and regulations surrounding healthcare.

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