Medicare Compliance & Reimbursement

Are you exempt from the Quality Payment Program?

To many, it feels like CMS is unloading one thing after another on the already heavy backs of providers nationwide, inhibiting workflow and increasing workload. Though MACRA is quite a bit different than the formulas used to equate payment under Medicare’s Sustainable Growth Rate (SGR), it aims to consolidate outlier programs, decrease paperwork, and increase revenue — and do it all with the hope of improving patient care.

If you feel overwhelmed, you are not alone. Take a look at these MACRA facts and see where you stand in CMS’s current rumble in the Medicare jungle.

There Are Always Exceptions in Medicare

Many clinicians will not qualify for the Merit-based Incentive Payment System (MIPS), and therefore won’t be required to send their data to CMS or suffer the penalties for CY 2017.

Refresher: MIPS is the introductory level of MACRA’s Quality Payment Program (QPP) that consists of four parts — quality, improvement activities, cost, and Advancing Care Information (ACI). Provider data is measured by the criteria in the categories, and your score determines the level of your Medicare payment.

Reality: For instance, “if this is the very first time you’ve enrolled in Medicare, then you’d be exempt,” explains Molly MacHarris, CMS program lead for MIPS and CCSQ in a Feb. 3, 2017 CMS webinar about the QPP impact on small, rural, and underserved practices.

Those already significantly entrenched in the Advanced Alternative Payment Models (APMs) side of MACRA who receive 25 percent of their Medicare pay through this system or who see 20 percent of their patients utilizing the Advanced APM options are exempt, too. Here is the comprehensive list of all the current Advanced APMs: https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf.

CMS Lowers the Bar For Small Practices

“CMS considered creating different performance criteria for small practices but determined that different performance criteria levels would create additional confusion and burdens,” says Sarah Warden, Esq of Greenspoon Marder in Ft. Lauderdale, Florida. Instead, they modified the QPP and eased up on the reporting measures to make it equal across the board.

“For example, CMS reduced the number of activities for small practices to achieve full credit in the clinical improvement category, simplified the Advancing Care Information reporting requirement, and increased the low volume exclusion threshold to exclude clinicians from MIPS that have minimal encounters with Medicare fee-for-service beneficiaries or low Medicare Part B charges,” Warden explains.

Remember: However, it is true that if you bill Medicare more than $30,000 a year and administer care to over 100 Medicare beneficiaries annually, that you will be required to report your measures under MIPS even if you are a small practice.

The “and” is the key to the criteria, suggests MacHarris — you must bill over $30,000 and you must see more than 100 patients. Consider this scenario: an eligible clinician bills $100,000 in Medicare claims, but only sees 80 patients during a calendar year. This provider would not qualify for MIPS because he did not meet the requirements to participate.

Reminder: “Eligible clinicians that provide services for a Rural Health Clinic or a Federally Qualified Health Center will generally not be subject to MIPS because RHCs and FQHCs are not paid under the Physician Fee Schedule,” says Warden.

MU exemptions. Medicaid is on the MIPS sideline, too. “It’s important to note that Medicaid EHR Incentive programs [Meaningful Use] will continue as will the Medicare EHR Incentive programs for hospitals,” MacHarris reminds. “MIPS and the QPP have no impact on those sides of the EHR Incentive Payment programs.”

There Is Help for Those Who Need It

Whether your practice is big or small, in the city center or along a rural highway, CMS, your Medicare Administrator (MAC), and most of the specialty group organizations have online tools to guide you through the reporting process.

Federal offerings. Public comments and stakeholder worries made a difference in the way CMS reorganized MIPS for small and rural practices over the last year. “To address this challenge, starting in early 2017, small and rural practices can begin to take advantage of CMS’s direct technical assistance program called QPP-SURS,” says Warden. “This program offers free customized support provided by quality improvement organizations to help these practices succeed in the MIPS performance categories or to transition into alternative payment models, such as ACOs.” Here’s a link to the MIPS small and rural practice fact sheet: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/small-practices-fact-sheet.pdf.

Three options. Because the QPP snuck into the Medicare vernacular while many were still trying to figure out ICD-10, eligible clinicians everywhere need help getting a handle on the transition. Some may not realize that MACRA and its initiative are already underway as the first reporting period opened on Jan. 1, 2017.

In an effort to offer guidance to all healthcare workers affected by MIPS, CMS has added some nifty tools for confused adopters. Here are three organizations “on the ground to provide help to clinicians who are eligible for the QPP:”

• Transforming Clinical Practice Initiative (TCPI) offers clinicians assistance and support with the transition to quality, pay-for-performance care under MACRA and how to adapt to these new initiatives. The networks are open to over 140,000 practices nationwide and will be available for advice for four years.
• Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs). There are currently 14 QIN-QIOs designed to bring “Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality,” the QPP factsheet says.
• APM Learning Systems help providers who utilize an APM that is not an Advanced APM be successful under MIPS.

Resource: For more information about TCPI, QIN-QIOs, and APM Learning Networks, visit https://qpp.cms.gov/docs/QPP_Where_to_Go_for_Help.pdf.