July 26, 2017

No matter how you participate in MACRA—individually or as part of a group—there’s a cost to being unprepared. Here’s what you should know.

1. What Is MACRA?

The Medicare Access and CHIP Reauthorization Act— MACRA—presents a new approach to payment for most physicians and clinicians who participate in the Medicare Part B program. It’s an approach that is heavily focused on value, with risk-based payment adjustments for quality, cost and more.

2. Who Participates?

Clinicians who are part of an Advanced Alternative Payment Model (APM) already participate in the Medicare Quality Payment Program. Other eligible clinicians (ECs) that are required to participate or risk receiving a negative payment adjustment in 2019 include:

  • Those who bill more than $30,000 in Medicare Part B allowed charges
  • Those who provide care for at least 100 Medicare Part B patients

Clinicians exempt from year one: first-year Medicare Part B participants and those who do not meet the minimum thresholds for participation (those who bill less than $30,000 in Medicare Part B allowed charges or who provide care for fewer than 100 Medicare Part B patients).

3. Choose Your Adventure

There are two tracks for participation under MACRA.Merit-Based Incentive Payment System (MIPS): In 2017, CMS estimates that 90 percent MACRA-eligible clinicians will report under MIPS.1 These include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.There are three options for participation in MIPS this year:

  • Report on one quality measure or improvement activity or the required advancing care information measures for 90 days.
  • Report on more than one of the above for 90 days.
  • Submit MIPS data for the full calendar year - this will include six quality measures, one of which must be an outcome measure.

Advanced Alternative Payment Model (APM): If you receive 25% of Medicare covered professional services payments through an APM or see 20% of your patients through an APM in 2017, you could qualify for this track.

4. Mark Your Calendars

The first performance year for MACRA began Jan. 1, with the financial impact being felt in 2019. Keep these key dates in mind:

  • October 2, 2017: Deadline to begin reporting on one quality measure for 90 days in 2017. Perform this minimum requirement and you’ll avoid a penalty in 2019.
  • March 31, 2018: Report the quality data you’ve collected. Depending on how much data you’ve collected, you could qualify for a small, positive payment adjustment or a bonus.

5. Scoring Is Competitive

MACRA is a competitive scoring program for clinicians, with clinicians receiving a composite score for their performance across categories.For MIPS, scoring categories comprise of:

  • Quality
  • Clinical Practice Improvement Activities (CPIA)
  • Advancing Care Information (formerly Meaningful Use) (ACI)
  • Cost (in 2018 and beyond)

CMS will set a performance threshold each year that equals the mean or median of all MIPS scores from the prior period.

6. How Are MIPS Scores Calculated?

60 percent quality, 15 percent CPIA, 25 percent ACI

In 2017, 60% of the MIPS score will be based on the quality data submitted.Cost will not be evaluated until 2018.

7. I’m a MIPS Eligible Clinician. Am I at Risk for a Payment Adjustment?

Yes—unless you meet the minimum qualifications for avoiding a negative payment adjustment (for example, reporting quality data around one measure for 90 days this year). Under MIPS, payment adjustments will range from negative 4% to 4% in 2019 based on participation and performance this year. CMS estimates approximately 90 percent of MIPS-eligible clinicians will receive a positive or neutral payment adjustment.2

8. Are Bonuses Available?

Based on their scores, some MIPS participants could qualify for an exceptional performance bonus. Qualifying APM participants could receive a 5% Medicare Part B incentive.

9. Your Score Will Be Public

MIPS scores will be publicly reported on the Physician Compare website and available to third-party vendors—so putting your best foot forward in 2017 is key.

10. Learn More

Visit the Centers for Medicare & Medicaid Services’ Quality Payment Program site or schedule a consultation with our MACRA experts to develop a plan for meeting reporting requirements. Email info@pulseinc.com or call 800.444.0882.

1 https://www.hfma.org/Content.aspx?id=540652 https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

Sonya Bess


Sonya Bess is currently the Government Initiative Specialist for Pulse. It is an exciting time in healthcare; physicians are taking on the new paradigms for standardized data-driven operational processes to support national healthcare goals. Anticipating the many changes that medical practices are facing as part of the eHealth Initiative, physicians continue to look for practical solutions to meet the ever changing demands of administrative compliance while maintaining excellent patient care. As part of a dynamic team Sonya has positioned herself as a liaison for healthcare professionals to assist in reaching these goals.