Medicare Compliance & Reimbursement

Take a look at these requirements to see if you are expected to transition.

As CMS shifts its focus from quantity to quality care, many in healthcare are struggling to get a grip on what that means. The MACRA-backed Quality Payment Program (QPP) and the options for success have been adjusted since its original outline last April to assist Medicare providers and their staffs with the transition. CMS now only requires those eligible to report a minimum of 90 days worth of data for 2017 to ensure their Medicare pay remains neutral or increases slightly—this is a significant reduction from the original requirements as CMS hopes the ease of burden will spur more providers to embrace the changes.

Background. The QPP’s two tracks—Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS)—offer a plethora of opportunities for entry and reporting, which aim to incentivize performance, patient engagement, and coordination of care, assisting providers both professionally and financially with their delivery of care.

Know If You’re In or Out

Despite a nonstop media blitz devoted to MACRA and its objectives since April, many in healthcare are oblivious to the changes and may not even know if they qualify. “A recent survey performed by The Physicians Foundation found that only 20 percent of physicians are familiar with MACRA,” says Sarah Warden, Esq of Greenspoon Marder in Ft. Lauderdale, Florida. “That statistic is troubling considering the amount of money at stake.”

The basics. So, if you are confused about whether are not your participation as a Medicare provider is MACRA-worthy, take a look at these stats to see if you able to transition to the new payment plan.

MIPS is the Easiest Point of Entry

If you bill Medicare more than $30,000 a year and administer care to over 100 Medicare beneficiaries annually, you are expected to move into the QPP and report your data. But, “you must meet both the minimum billing and the number of patients to be in the program,” the QPP factsheet advises.

This track offers four paces of participation for those who want to abstain to those willing to dive in. The levels of entry are:

1. Non-participation despite meeting the qualifications. Failure to report any data for the CY 2017 when you match the MACRA thresholds yields a 4 percent negative impact on your payments.
2. Minimal participation. This allows you the options of just sending in one quality measure or compliance activity for the entire year. You won’t see an increase but you won’t be penalized either.
3. Partial participation. This might turn out to be the most popular pace as you are only required to report 90 days of data for the entire CY 2017 with the possibility of a positive payment increase.
4. Full participation. If you are ready to reap the rewards of offering quality care, you can report your entire 2017 data to Medicare, covering the four categories required under MIPS. If your score qualifies, you’ll see a 4 percent Medicare payment increase, paid out in 2019.

Reminder: Don’t forget MIPS does have four distinct categories that cover criteria that must be met in order to receive that coveted incentive. Take a look at the quick go-to list below for reference when making your decision on your level of participation:

Advanced APMs Are Designed For the Risk Taker

If you are participating in an Advanced APM already, you will be part of the QPP. For those invested in this track, the risk is higher but so is the reward.“If you receive 25 percent of Medicare payments or see 20 percent of your Medicare patients through an Advanced APM in 2017, then you earn a 5 percent incentive payment in 2019,” the QPP factsheet suggests.

Most participants in this group have already begun implementing the highest level of CEHRT, providing value-based care under the existing models, and are pushing the envelope on the delivery and coordination of care in their fields.

Future opportunities. Currently, CMS lists seven Advanced APMs available to interested providers for 2017, who plan to go this route. Though the CMS Innovation Center has finalized others like the recently approved Cardiac and Orthopedic Care Coordination Models, which highlight bundling and multi-layered care, they are not listed yet as options for the CY 2017.

Here is the current list of approved Advanced APMs for the QPP in 2017:

• Medicare Shared Savings Program (MSSP) Track 2
• Medicare Shared Savings Program (MSSP) Track 3
• Comprehensive Primary Care Plus (CPC+)
• Next Generation ACO Model
• Oncology Care Model (Two-sided risk)
• Comprehensive ESRD Care Model (Two-sided risk)
• Vermont Medicare ACO Initiative (Part of the Vermont Medicare ACO model).

Tip: You may be exempt from MACRA if you don’t meet the threshold requirements, are new to Medicare, or service in a rural area. Check with your MAC or CMS directly to see if the exemption pertains to you.

For the complete QPP fact sheet with links to detailed information about the measures, scores, and more, visit https://qpp.cms.gov.