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What is the MACRA Final Rule?


On October 14th, 2016 CMS issued the MACRA final rule, which introduced the Quality Payment Program (QPP), a new payment program set to begin on January 1, 2017. MACRA is landmark legislation which alters how Medicare reimburses physicians and other providers, and has three core functions:

  • Repeals the flawed sustainable growth rate (SGR)
  • Extends Children’s Health Insurance Program (CHIP) for two years
  • Creates a new two-track Medicare physician payment system emphasizing value-based payment models  

The program is in support of payment reform goals to increase quality of care and decrease cost of care by tying payments directly to quality and cost.

MACRA – Fast Facts

MACRA affects providers billing Medicare. Providers who meet certain criteria are required to participate in QPP – they are called “Eligible Clinicians.” If Eligible Clinicians don’t participate in, they will be penalized a percentage of their Medicare revenue.

Proposed quality scoring is public.

All reporting performances will be publicly reported on Medicare’s Physician Compare site.

The QPP performance year starts on 1/1/2017 and an Eligible Clinician’s payment adjustments for the 2017 performance year will be reflected in 2019 payments (there’s always a 2 year lag between performance and payment adjustments). The QPP covers payment adjustments through 2024.

The term “Eligible” Clinician really means “required.”
If a provider fits the Eligible Clinician criteria (see next bullet point), that means they must comply with the QPP and report either MIPS or APMs. If they fail to comply in 2017, they will be penalized 4% of their Medicare Part B allowables in 2019. Each year, the penalty payments increase.

Eligible clinician definition: Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists who see >= 100 Medicare patients AND bill more than $30,000 in Medicare Part B allowables. These numbers are PER individual, per year. In a group practice, there may be some providers who will have to participate in the QPP and others who do not. The QPP is only for Medicare.

QPP officially sunsets existing PQRS, VM and MU Medicare ambulatory programs.
2016 MU, PQRS and VM performance year is the last year impacting payment adjustments (in 2018). These programs are now rolled up under MIPS and will be recorded as MIPS category measures.

Medicaid MU and Hospital MU programs will continue. The QPP doesn’t affect hospital MU and Medicaid MU programs. This means some providers might have to report for all three!

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