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Answering your questions about MACRA

Understanding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is vital because it changes how Medicare pays physicians for services as well as care delivery. It moves away from fee for service to value-based care. Not understanding the new policies, passed on October 14, 2016, will result in a penalty of negative 4 percentage!

Those who work in the healthcare industry must be prepared for these changes or it will cost you.

Recently, industry expert Tina Colangelo delivered a webinar for Medical Office Manager subscribers and reviewed the necessary information you need to maximize your return and keep your practice afloat in the coming year. Due to the overwhelming response, we invited Tina back to deliver an encore presentation of her webinar.

If you’re a premium member of Medical Office Manager, you can review both webinars and presentation slides here:

There were a lot of questions asked during the webinar and, due to time constraints, we weren’t able to get to all of them. But we did promise attendees we’d share the answers as soon as we could. So, as promised, here are the questions and Tina’s answers.

Question: What is the volume threshold to be eligible for MIPS?

Answer: Eligible clinicians have to have $30,000 Medicare charge AND see 100 Medicare patients.

Question: Are the PQRS measures the same as the 2016 and are there still measures groups to report on?

Answer: Yes, the measures have not changed. CMS has added some new measures. And, yes there are still measure groups to report on, but if you’re reporting as a group, you cannot use a measure group.

Question: How many measures do you need to report on for ACI performance category?

Answer: You need to report on the 5 base measures plus 8 additional measures to satisfy the requirement.

Question: Where do I get a list of Clinical Improvement Activities?

Answer: Go to

Question: We belong to the largest OB/GYN group in Florida. There are over 250 providers. Two providers do not qualify for MIPS but two probably will. Do we report as a group or check with the MSO?

Answer: Check with the MSO first, but usually it depends how everyone’s TINS and NPIs are tied together with CMS.

Question: Is a doctor who just starting seeing patients in December 2016 eligible to participate in MIPS in 2017?

Answer: No. If it’s your first year, then December 2016 through December 2017 the doctor is not eligible for MIPS. I would encourage the doctor to be prepared so when he/she becomes eligible, they can jump right in

Question: How many people are using a consulting firm?

Answer: Many healthcare organizations are using consultants to help navigate the tsunami of it all.

Question: How will doctors who use a billing service report?

Answer: Doctor will have to report her/himself or designate a staff member to report on her/his behalf or hire a registry to assist with the reporting. The billing service does not report for eligible clinicians.

Question: Is the individual provider date the same as the group registration date?

Answer: No it is not the same. Group reporting need to reassign TIN/NPI by 6/30/17 or be subject to report individually.

Question: Will physical therapists need to continue to report for PQRS in 2017?

Answer: Physical therapists need to continue to report for PQRS 2016 to receive payment adjustment in 2018 but will not be in MIPS 2017. CMS will add physician therapists in the following years of the program

Question: With option 1, how many patients do we have to report on?

Answer: Report one measure on one patient to avoid the penalty

Question: Can we continue with claim based reporting?

Answer: Yes.

Question: Do we need to attest like Meaningful Use?

Answer: Yes.

Question: Are ophthalmologists on the list?

Answer: Yes.

Question: If MIPS is budget neutral, if more providers participate and earn a 4% incentive than providers that don’t meet their standards and receive a -4% pentalty, how will Medicare pay out the 4% incentive?

Answer: It is a budget neutral system based on an adjustment factor. Let’s say there were 10 providers who met criteria and met the incentive and 5 providers who received a penalty. The lump sum from the 5 provider’s penalty is dispersed to the 10 providers who met the criteria based on an adjustment factor-which cannot be determined until after performance year 2017. So, there is no difference in money. If 98% of clinicians reported successfully, the pool of money would only come from 2%.

Question: Where do you find your QRUR?

I have attached a copy of the instructions on how to access your QRUR report. The other attachment is just in case you are a new user; then there are additional steps.

Guide for Obtaining a New User EIDM Account with a Physician Quality and Value Programs Role

2015 QRUR Guide

What Providers Can Do With Their QRURs

Question: How do you decide if it is best to report as an individual or as a group?

Answer: It depends on who is in your “group.” If you report as a group everyone within your group will receive the same payment adjustment based on combined group’s performance. This could be negative for high performers.

An example, if the data you submit justifies you to receive a Medicare reimbursement increase, but remainder of your group actually qualifies for a decrease, you’ll be paid on the combined rate, which is in this case you will not get a positive payment adjustment.

I tell all of my clients who are thinking about joining a group, to make it a point to know their payment adjustment score before signing on. Now, this works both ways. If your scores are not up to par, join a group with high scores.

A con to reporting as a group is you will not have the option to report via claims submission. To report as an individual means bearing full responsibility for your reportable data.

So, the key is knowing the group’s scores beforehand. Most of my clients report as group.

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