On Friday, Oct. 14, CMS issued the final Merit-Based Incentive Payment System (MIPS) rule under the Medicare Access and CHIP Reauthorization Act of 2015, also known as MACRA. 

MIPS will start with a 4-percent impact on Part B payment to eligible clinicians, with that shift ultimately climbing to 9 percent. Initially, eligible clinicians are classified as physicians, osteopaths, dentists, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.   

Actions by these clinicians in 2017 will determine whether they receive a payment adjustment in 2019. The good news is that with some effort, it will be possible to avoid a payment reduction in 2019. But doing so will be more difficult in subsequent years. In 2019, physical and occupational therapists, speech language pathologists, audiologists, midwives, clinical social workers, psychologists, and dieticians/nutritionists will become eligible clinicians. 

The final rule is 2,400 double-spaced pages, meaning not only is it impossible to summarize it in this segment, reading all of it will be a superhuman task. To avoid facing a payment reduction in 2019, eligible clinicians must report at least 90 days of data for one of three items. You can report two or more quality measures, two or more improvement activities, or exceed the required measure of advancing care information. If you fail to do one of these, your Medicare payments in 2019 will be trimmed by 4 percent unless you meet one of the exceptions to the rule. If you want to be eligible for a bonus, you will have to do more than this minimum, as I will explain in a moment.   

One exception applies to clinicians who are in certain Alternative Advanced Payment Models. Not every payment model will qualify – only those listed by the Centers for Medicare & Medicaid Services (CMS) on its website. Small practices that have 100 or fewer Medicare patients or allowed charges of $30,000 or less will not need to report. These small-volume providers are truly outside the scope of MIPS because they will not be eligible for a bonus even if they choose to report. 

As I was reading the CMS summary of the rule, I found myself somewhat overwhelmed. Understanding this program will be a significant undertaking. No one is required to do anything due to this rule, but there are serious Medicare payment implications, with the 4-percent reduction in 2019 increasing to 5 percent in 2020, then 7 percent the next year and 9 percent in 2022. 

It is difficult to understand this in the abstract. Perhaps the easiest way to get a basic understanding of the proposal is to look at the proposed rule, which can be found online at https://qpp.cms.gov/docs/CMS-5517-FC.pdf.

Jump to page 2,085, where a long list of quality measures appears. To be eligible for a bonus, a professional must choose six, including an outcomes measure, unless there aren’t six that apply to their profession, in which case the professional must report all that apply. The list of improvement activities can be found at page 2,382. The list is organized by the weight of each measure. To be bonus-eligible, most individuals must perform four medium-weighted or two highly weighted activities (a reduction from the proposed rule). Professionals in rural or health professional shortage areas and non-patient facing professionals need only perform one highly weighted to two medium-weighted activities. 

The good news is that we can ease into this a bit. If you are up and running on these measures by next Oct. 1, you can meet the obligation to report 90 continuous days. But if you have any of the eligible professionals, someone in your organization has some work to do. Remember that this program only affects payments to individual professionals. Entities such as hospitals and nursing homes are not directly affected by the rule, although there was a reference indicating that hospitals are required to “cooperate” with certain information sharing. I haven’t yet fully analyzed that provision and can’t offer more detail. 

CMS will be accepting additional comments for 60 days after the rule appears in Federal Register, so if you see something in the rule that piques your interest, you may send a comment either electronically via http://www.regulations.gov, by following the “submit a comment” instructions or via regular mail to the Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-5517-FC, P.O. Box 8013, Baltimore, MD 21244-8013.

About the Author

David M. Glaser, Esq., is a shareholder in Fredrikson & Byron’s Health Law Group. David helps clinics, hospitals, and other healthcare entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David’s goal is to explain the government’s enforcement position and to analyze whether the law supports this position. David is a popular panelist on Monitor Mondays and is a member of the RACmonitor editorial board.

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