The MACRA Maze

As you may have heard, the permanent doc fix is here, MACRA (Medicare Access & CHIP Reauthorization Act). 

The new legislation emphasizes quality by replacing a quilt work of existing programs. It also adds an additional category, Clinical Practice Improvement Activities, and places all programs under one Quality Payment Program (QPP) umbrella.

  • Do you find MACRA confusing?
  • Have you received cryptic notifications from CMS that you have failed to achieve quality (PQRS), Electronic Health Record (EHR) or cost (Value Modifier) benchmarks that will result in payment penalties?
  • Has all of it been an administrative nightmare?

The good news? You may not have to hassle with any of it!

According to CMS, the absolute first action item related to the Quality Payment Program (QPP) is to determine your eligibility status. If you are not eligible for the QPP, you need not worry about the administrative energy or negative payment repercussions of not participating.

With regulations issued during the Fall of 2016, CMS spelled out who is in and who is out.

  • IN: If you are a defined clinician (i.e. a Physician, a Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist or a Certified Registered Nurse Anesthetist).
  • OUT: If your Medicare Part B clinician billings are less than or equal to $30,000 a year or if providing care to less than or equal to 100 Medicare patients a year.

Given these thresholds, approximately 32.5% of pre-exclusion Medicare clinicians are not subject to the QPP and the effort required to adhere to its provisions, according to CMS. Additionally, if you are small practice (15 clinicians or fewer) subject to the QPP, accommodations have been made to ease the administrative burden.

As we march into the Quality universe, it is wise to know all the steps required as you get started, and to follow the path of least resistance. Start with determining what your eligibility status is!

About the Author



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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