MACRA MIPS Quality...Are You Prepared

Under Medicare, the CMS (Centers for Medicare and Medicaid Services) is wrapping four quality programs under one umbrella.


Two of the paths under MACRA are:

  • MIPS (Merit Based Incentive Payment) and
  • APM (Alternate Payment Model).  

We’ll concentrate on MIPS – which at least initially, most eligible clinician will be subject to.

Wondering if you are even subject to the new Medicare Quality Payment Program? Check out our previous blog, How MACRA Could Affect Your Revenue Cycle? 

The four core elements under MIPS are:

  • Quality
  • Cost & Resource Use
  • CPIA (Clinical Practice Improvement Activities)
  • ACI (Advancing Care Information) 

Of the four, quality represents a whopping 50% of the score! Assessing your readiness will be essential for quality. 

Here are the three categories you will fall into when it come to readiness:

  1. Unprepared – A reporting option has not been explored/implemented. PQRS (the Physician Quality Reporting System) has not been performed in the past. Eligible clinicians or groups have not selected the appropriate quality measures and thus, the info will not be extracted from the EHR. Actual submission of the data file for the reporting period is not on the docket.
  2. Partially Prepared – Some of the unprepared attributes mentioned above, have been undertaken;
  3. Fully Prepared and ready to go! - Management is fully behind the effort, and knows the multi-faceted costs of not participating. PQRS has been successfully consummated in the past. Eligible clinicians/staff are educated on the initiative. A budget is set to make it happen. IT infrastructure is in place (i.e. the CMS specified identity management system in on track, a test data file to CMS is in the offing, etc.). Planning/execution is taking place for the reporting period of 2019.

Please note that recently CMS issued a statement allowing Providers to pick the level and the pace of participation, and the points above must weigh into that decision. This in itself will enable eligible clinicians to ease into the program. Eligible clinicians that find themselves in an unprepared state may want to opt for the first option CMS has laid out, which is to test the quality payment program (this will negate a 2019 negative payment adjustment). For those partially prepared, the second CMS option to participate for part of the calendar year may be the way to go. And for those fully prepared, participation for the full calendar year should advance, while eying more advantageous APM opportunities.

Lastly, CMS estimated the burden for the MIPS Quality reporting program is about $723 per eligible clinician. Plus, CMS estimates, the majority of the MIPS underperformers fall in practice sizes of 24 clinicians or less (with almost 60% with a negative payment adjustment). The hardest hit will be the solo providers, with a projected 87% being hit with a negative payment adjustment in 2019.

At this juncture, carefully assess your preparedness and follow the right passageway.


Kerry Luciani


Kerry has over 30 years of healthcare revenue cycle management experience on both the payer and provider side. Over the course of his career, Kerry has developed an abundance of expertise in Medicare Part B reimbursement and has published several comments in the Federal Register.

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