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MACRA Quality Payment Program for Emergency Physicians


Final details of the MACRA Quality Payment Program (QPP) for the 2017 reporting year were recently released by the Centers for Medicare and Medicaid Services (CMS). While much of the proposed rule was included in the final draft, CMS made a few provisions especially for small practices, hospital-based clinicians, and eligible providers who aren’t quite ready to dive in for 2017.

The Medicare Access and CHIP Reauthorization Act of 2015 was passed by Congress last year to abandon the flawed Sustainable Growth Rate formula and create a new payment growth structure for the Medicare program. MACRA implemented a .5 percent annual rate increase for Medicare Payments through 2019, after which payments would be adjusted either positively or negatively based on providers’ performances through the two-pronged Quality Payment Program, which includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APM).

MIPS replaces and combines several different quality programs established by CMS over the years, including Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier to incentivize high quality, low cost services, along with certified EHR use.

Eligible Providers

Eligible providers for the QPP include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Under the final rule, any provider who has less than $30,000 in Medicare Part B charges or fewer than 100 Medicare patients per year would be exempt from program.

According to Dr. Patrick Conway, deputy administrator for innovation quality, CMS CMO, this low-threshold exemption could represent as many as 380,000, or 32.5 percent of, Medicare clinicians. Another 200,000 providers, or approximately 14.4 percent, are not among the eligible types of clinicians and also will not be required to participate.

That leaves about 600,000 clinicians who will have to decide how to participate in the QPP for the 2017 reporting year. CMS estimates up to 120,000 clinicians (approximately 5-8 percent of all clinicians billing under the Medicare Part B) will participate in Advanced APMs, and another 480,000 or so will participate in MIPS.

Although many very small practices will be exempt from the QPP program, CMS has earmarked $20 million each year for five years to train and educate Medicare clinicians in small practices of 15 clinicians or less and providers working in underserved areas.

When Do We Start

The first QPP reporting period begins January 1, 2017, and the first positive or negative payment adjustments will be applied beginning January 1, 2019. Performance data for the 2017 reporting year is due March 31, 2018.

What’s At Stake

Eligible providers who choose not to participate in any way will receive an automatic 4 percent negative payment adjustment in 2019. Payment adjustments gradually increase over the years to 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022. Providers who do participate also are subject to the same negative payment adjustments if they are found to provide poor quality, high cost services that do not rely on certified EHR use. Providers who do the opposite, who provide high quality, low cost service using certified EHR technology, have the potential to earn positive payment adjustments of 4, 5, 7, and 9 percent in the same years.

Like the Value-Based Payment Modifier program, MIPS is budget neutral, which means any positive payment adjustments are paid out of money CMS retains through the negative payment adjustments. Also, CMS has set aside an additional $500 million to reward exceptional performers in the MIPS program each year of the first 6 years of the program. For 2017, exceptional performers are those who earn a final score of 70 or higher on a 100-point scale.

How to Participate

The first year of the QPP is a transitional year. Providers can choose one of four ways to participate in 2017, what CMS is calling “Pick Your Pace”:

  • “Test” the program by submitting a minimum amount of data – one quality measure, for example – to ensure physicians’ systems are working and prepared for broader participation in the next years.
  • Submit 90 days of 2017 data, which would allow practices to submit for their first performance period any time between January 1 and October 2, 2017, avoid a negative payment adjustment, and still qualify for a small positive payment adjustment.
  • Submit a full year of 2017 data which could result in a positive payment adjustment and insulate against a payment adjustment.
  • Join an Advanced APM, which involves more risk, but offers providers who receive 25 percent of Medicare payments or see 20 percent of Medicare patients through an Advanced APM the ability to earn up to a 5 percent incentive payment in 2019.

In addition to the 2017 program modifications, CMS also has indicated that additional transitional provisions may extend into the 2018 reporting period as well.


Providers who choose the MIPS option will be required to submit data in only three of four eventual categories, including the following:

  • Quality – 60 percent of final score: report up to 6 quality measures, including an outcome measure. As with PQRS, there are several reporting methods, including claims. A list of measures is available for review on the CMS website and can be sorted by data submission method and specialty. MIPS includes several quality measures for emergency physicians in both the claims and registry reporting categories, as well as a limited number of measures in the EHR reporting option.
  • Clinical Improvement Activities – 15 percent of final score: attest that you completed up to 4 improvement activities.
  • Advancing Care Information – 25 percent of final score: fulfill the five required measures, including Security Risk Analysis; e-Prescribing; Provide Patient Access; Send Summary of Care; Request/Accept Summary of Care. Choose to submit up to 9 measures for additional credit.

Beginning in 2018, CMS also will include a cost performance category in the MIPS program. By 2022, cost will count for 30 percent of the final score, pulling weight from the quality category.

Providers who share a common Tax Identification Number can report MIPS as a group regardless of their specialty or practice site. Groups must register by June 30, 2017, to take advantage of this option. MACRA will eventually allow solo and small practices of no more than 10 clinicians to join “virtual groups” and combine their MIPS reporting, although this option is not available in 2017.

Because MIPS replaces several different Medicare quality programs, some eligible providers for MIPS may not have been required to participate in certain previous quality programs. For instance, hospital-based clinicians, like emergency physicians, were exempt from the EHR Meaningful Use program. In order to address these issues, CMS has provided flexibilities in the program to assign different scoring weights (including a weight of zero) for each performance category if there are not sufficient measures and activities applicable and available to each type of MIPS eligible clinician, including hospital-based clinicians.

A hospital-based clinician is defined as follows under MIPS: a MIPS eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by the Place of Service (POS) codes 21, 22, and 23 used in the HIPAA standard transaction as an inpatient hospital, on campus outpatient hospital, or emergency room setting in the year preceding the performance period.

Some MIPS guidelines also apply only to providers who have face-to-face encounters with patients, including emergency physicians.

A patient facing MIPS eligible clinician is defined as follows under MIPS: an individual MIPS eligible clinician that bills more than 100 patient-facing encounters (including Medicare telehealth services during the non-patient facing determination period) or a group with more than 25 percent of the NPIs billing under the group’s TIN who meet the definition of a patient facing individual MIPS eligible clinician during the determination period.

The non-patient facing determination period for the 2017 reporting year will initially be based on 12 months of data starting from September 1, 2015 to August 31, 2016. In order to identify any additional individual MIPS eligible clinicians and groups that may qualify as non-patient facing during the 2017 performance period, CMS will conduct another eligibility determination analysis based on 12 months of data starting from September 1, 2016 to August 31, 2017.

Advanced APM

Providers who participate in an advanced APM can earn a 5 percent lump sum incentive payment each year from 2019 through 2024 and avoid MIPS reporting requirements and payment adjustments.

Approved Advanced APMs for 2017 include the following:

For more information about the MACRA QPP, review the Executive Summary or the entire Final Rule. CMS also has developed a Quality Payment Program website to help providers explore their options and plan their participation. In addition, the American College of Emergency Physicians regularly posts about issues related to MACRA on their Regulatory Issues webpage. Finally, you also can register for the following CMS event:

Quality Payment Program Final Rule MLN Connects® Call — November 15

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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