MACRA, QPP, and MIPS: A Basic Overview

Today, we’re diving into MACRA, QPP, and MIPS, essential components directly impacting how you’re reimbursed for healthcare services to Medicare Part B insured patients. So, let’s get started!

MACRA and the Shift to Quality:

Before 2015, Medicare reimbursement was based on the Sustainable Growth Rate (SGR). Still, with an increasing aging population and more people enrolling in Medicare, the government recognized the need for a more sustainable and value-based approach. This led to the creation of MACRA (Medicare Access and CHIP Reauthorization Act), shifting reimbursement from quantity to quality. Within MACRA, the Quality Payment Program (QPP) is designed to incentivize providers to deliver high-quality care.

Understanding MIPS:

MIPS (Merit-based Incentive Payment System) is crucial to the QPP. It’s a detailed framework that evaluates providers based on specific criteria to determine their reimbursement rates. Providers can choose which criteria to focus on and must meet certain thresholds to qualify for reimbursement incentives.

The Three MIPS Criteria:

To qualify for MIPS reporting, providers must meet all three of the following criteria:

1. Bill $90,000 or more in Medicare Part B claims within 12 months.
2. See more than 200 Medicare Part B patients.
3. Provide over 200 Medicare Part B services.

Remember, if you need more clarification about meeting these criteria, it’s better to assume you’ll have to report MIPS data.

Key Steps for MIPS Reporting:

1. Use Certified Electronic Health Record Technology (CEHRT): Ensure your EMR or EHR system is CMS-certified for MIPS reporting.
2. Monitor Progress: Assign someone in your clinic to track your MIPS progress throughout the reporting period.
3. Reporting: Decide if you or your representative will report the MIPS data to CMS. While it may incur an additional cost, having your EHR provider handle the reporting can be advantageous.

Categories and Specialties:

MIPS reporting involves certain data points for all specialties, such as smoking status and race/ethnicity. However, providers also get to choose specialty-specific criteria to focus on. The percentage of patients you see within a specific timeframe for each category will determine your reimbursement incentives or penalties.

Stay Updated and Communicate:

Staying informed about MIPS requirements is essential. Regularly communicate with your EHR provider and on-site staff overseeing MIPS monitoring to identify areas of improvement and ensure successful reporting.

Navigating the intricacies of MACRA, QPP, and MIPS can be overwhelming, but it’s vital for healthcare providers who see Medicare Part B insured patients. By understanding the criteria, using certified technology, and staying informed, you can optimize your MIPS reporting and potentially increase your reimbursement. If you have any questions or experiences to share, please leave a comment below. Together, let’s master MACRA, QPP, and MIPS for better patient care and practice success!