MACRA Quality Payment Program Resource Center

Learn more about the Quality Payment Program, MIPS, Advanced APMs, and how value-based reimbursement will impact your practice.

MACRA Quality Payment Program Eligibility Assessment

Find out if you will participate in MIPS or Advanced APMs or are excluded from the QPP.

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Frequently Asked Questions

What is MACRA?

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MACRA is the Medicare Access and CHIP Reauthorization Act, which is legislation that replaced the Sustainable Growth Rate (SGR). It outlines a new program for physician reimbursement that replaces fee-for-service with value-based payments under the Quality Payment Program (QPP).

What is the Quality Payment Program?

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The QPP is the portion of MACRA that defines the new value-based reimbursement system. It has two parts: the Merit-Based Incentive Program (MIPS) and Advanced Alternative Payment Models (APMs). The QPP replaces and consolidates the current Medicare Meaningful Use, PQRS, and value-based modifier programs.

Who Participates in the QPP?

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The following provider types must participate in the QPP in either MIPS or Advanced APMs:

  • Physician (Doctors of Medicine or Osteopathy, Doctors of Dental Surgery or Dental Medicine, Doctors of Podiatric Medicine, Doctors of Optometry, Chiropractors)
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist

Are there exclusions to the eligible provider?

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Yes, the following providers are excluded from the QPP in 2017:

  • Providers in their first year of Medicare in 2017.
  • Providers who see fewer than 100 Medicare patients each year.
  • Providers who bill $30,000 or less in annual Medicare claims.
  • Providers who are participating in an Advanced APM.

What qualifies as an Advanced APM?

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The following are the approved Advanced APMs for 2017.

  • Comprehensive ESRD Care (CEC) – Large Dialysis Organization (LDO)
  • Comprehensive ESRD Card – Non-LDO
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (two-sided risk arrangement)

If you receive 25% of Medicare payments or see 20% of your Medicare patients through an Advanced APM, then you may earn a 5% incentive payment in 2019. You do not participate in MIPS. You will report your data through your APM.

What Are the Requirements for MIPS?

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Most providers will participate in MIPS not Advanced APMs in 2017. Under MIPS, providers’ Medicare reimbursements will be adjusted up or down based on how they score across 3 categories:

  1. Quality (60%) - Replaces the old PQRS system, but is very similar in that it requires providers to report on quality measures.
  2. Advancing Care Information (25%) - Replaces Medicare Meaningful Use, but is very similar in that it requires providers to use a certified EHR to report measure objectives.
  3. Improvement Activities (15%) - Practices must attest that they have implemented documentation, workflow, or process improvements.

Do You Need a Certified EHR to participate in the QPP?

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Yes, for both MIPS and the Advanced APMs, you need a certified EHR. For 2017 the EHR must be either 2014 or 2015 Edition certified. Starting in 2018, the EHR must be 2015 Edition certified.

How do I find out if my EHR is certified?

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Your vendor can tell you if your EHR is 2014 Edition certified to meet the requirements for 2017. However, you should also verify they will be 2015 Edition certified in time for 2018. You can also visit www.healthit.gov and search their list of certified EHRs.

What is the Quality requirement for MIPS?

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To meet the Quality requirement for MIPS for most participants, you must report up to six quality measures, including an outcome measure, for a minimum of 90 days. For those using the web interface, you must report 15 quality measures for a full year.

How many measures are there to choose from for Quality?

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There are 271 measures to choose from. You can select from those that best fit your practice.

What are the Improvement Activity requirements for MIPS?

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For most participants, the requirement for Improvement Activities for MIPS is to attest that you completed up to four improvement activities. For groups with fewer than 15 participants or if you are in a rural or health professional shortage area, the requirements is complete up to two activities for a minimum of 90 days. If you are in a certified patient centered medical home, you automatically get full credit.

How many improvement activities are there to choose from?

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There are 93 improvement activities to choose from.

What is the Advancing Care Information requirement for MIPS?

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To meet the requirement for Advancing Care Information you need to fulfill these required measures for a minimum of 90 days:

  • Security Risk Analysis
  • e-Prescribing
  • Provide Patient Access
  • Send Summary of Care
  • Request/Accept Summary of Care

You may also choose to submit up to nine measures for a minimum of 90 days for additional credit. And for bonus credit, you can also:

  • Report Public Health and Clinical Data Registry Reporting measures
  • Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

Please note that you may not need to submit advancing care information if these measures do not apply to you.

How many measures are there to choose from for Advancing Care Information?

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If you are using a 2015 Edition certified EHR you have 15 measures. If you are using a 2014 Edition certified EHR you have 11 measures.

How do we sign up for MACRA?

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The MACRA Quality Payment Program has two tracks: MIPS and Advanced APMs. You do not need to sign up for MIPS. You simply report your data during the reporting period. If you are in an Advanced APM you will report through that group. If you do not report at all, you will receive a -4% adjustment in 2019.

How will we report our data for MIPS?

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For the 2017 year, MIPS data will be reported via the same methods as the Meaningful Use and PQRS programs. These are claims, registry, QRDC, web interface and/or CMS EHR Incentive Payment Attestation Site. During this first year, providers will most likely need to report via two methods. For example, quality measures can be reported via all methods, except the Attestation Site. Advancing Care may be reported via web interface and the Attestation Web Site, while the Improvement Activities will most likely be reportable via registry and Attestation Site.

Is Medicare Advantage included or does this just apply to Medicare?

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This program only applies to Medicare Part B.

If I have been participating in MU, will I continue through 2017 along with MACRA?

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No, Medicare Meaningful Use is ending at the end of 2016. If you are participating in the Medicaid MU incentive program, and qualify for MIPS as well, you will participate in both programs.

Are mental health providers eligible clinicians?

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Non-physician mental health providers are not currently considered eligible clinicians under MACRA.

Are PTs, OTs, and SLPs eligible clinicians?

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PT/OT/SLP providers are not currently considered eligible clinicians MACRA, but they may be added in 2019.

Will there be similar incentives and penalties from commercial payers?

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Many commercial payers have already been switching to value-based care programs. Many believe they will follow suit and increase these programs and move more towards value-based programs over the next three to five years.

Do I participate in MACRA if I am doing Medicaid Meaningful Use?

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If you also accept Medicare Part B and have more than 100 Medicare patients or bill more than $30,000 in Medicare Part B claims then you would also participate in MACRA.

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Is Kareo Clinical 2014 Edition certified?

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Yes, Kareo Clinical is 2014 Edition certified.

Currently, I have Kareo Billing and no EHR. What are the next steps to get a certified EHR to participate in MACRA?

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You do need a certified EHR to participate in MACRA. There is a possible -4% adjustment on Medicare reimbursement in 2019 based on 2017 performance. So, don’t wait to get a 2014 Edition certified EHR in place so you can participate in 2017. Even minimum participation for 90 days can help you avoid the penalty. You can sign up for Kareo Clinical demo or call 888-775-2736 to speak to a Kareo Solution Consultant now.

Can the required data for MIPS be captured using Kareo Clinical?

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Yes Kareo Clinical will provide the fields necessary to capture data for both the Quality requirement and Advancing Care Information requirement under MIPS for 40 different measures by January 1, 2017. The measures focus on the following specialties: General Practice/Family Practice, Allergy, Internal Medicine, and Pediatrics. The system will have the reporting capabilities for these measures by the end of March, 2017. The late release of the final rule does not give vendors much time to make needed changes to software. Please be patient as we do our best to get you the features you need.

Will Kareo provide training on MIPS?

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Kareo is currently reviewing the entire rule and determining what additional training may be needed. Appropriate resources and training will be developed and released to customers as it is available.

What Quality Measures are available in Kareo Clinical?

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Kareo has selected measures common to a variety specialty sets. The Kareo EHR has created fields/processes for gathering the data for each of these measures. Additionally, Kareo is creating a Quality Measures Report that will show how a provider is doing on all 44 measures. The Report will be available by the end of the First Quarter of 2017.

MIPS QUALITY MEASURES SUPPORTED BY KAREO

  • 1. Diabetes: Hemoglobin A1 (HbA1c) Poor Control (9.0%)
  • 5. Heart Failure: Angiotensin-Convertin Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic
  • 8. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • 9. Anti-depressant Medication Management
  • 47. Care Plan
  • 65. Appropriate Treatment for Children with Upper Respiratory Infection (URI)
  • 66. Appropriate Treatment for Children with Pharyngitis
  • 91. Acute Otitis Externa (AOE): Topical Therapy
  • 93. Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
  • 110. Preventive Care & Screening: Influenza Immunization
  • 111. Pneumonia Vaccination Status for Older Adults
  • 112. Breast Cancer Screening
  • 113. Colorectal Cancer Screening
  • 116. Avoidance of antibiotic Treatment in Adults with Acute Bronchitis
  • 117. Diabetes: Eye Exam
  • 128. Preventive Care & Screening: Body Mass Index (BMI) Screening and Follow-up Plan
  • 130. Documentation of Current Medications in the Medical Record
  • 134. Preventive Care & Screening: Screening for Clinical Depression and Follow-up Plan
  • 163. Diabetes: Foot Exam
  • 181. Elder Maltreatment Screen and Follow-up Plan
  • 204. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
  • 226. Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention
  • 236. Controlling High Blood Pressure
  • 238. Use of High-Risk Medications in the Elderly
  • 239. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
  • 240. Childhood Immunization Status
  • 310. Chlamydia Screening for Women
  • 312. Use of Imaging Studies for Low Back Pain
  • 317. Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
  • 326. Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
  • 331. Adult Sinusitis: Antibiotic Prescribe for Acute Sinusitis (Overuse)
  • 332. Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulante Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
  • 333. Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
  • 334. Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
  • 374. Closing the Referral Loop: Receipt of Specialist Report
  • 378. Children Who Have Dental Decay or Cavities
  • 383. Adherence to Antipsychotic Medication for Individuals with Schizophrenia
  • 387. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
  • 391. Follow-up After Hospitalization for Mental Illness (FUH)
  • 394. Immunizations for Adolescents
  • 401. Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in patients with Cirrhosis
  • 402. Tobacco Use and Help with Quitting Among Adolescents
  • 431. Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
  • 438. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

What Improvement Activities may be documented in Kareo that enable us to earn extra points?

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A set of 18 improvement activities have been identified as tied to the objectives, measures, and CEHRT functions of the Advancing Care Information performance category. Successful completion of any of these activities can qualify the provider for a bonus in the advancing care information performance category. Sixteen of the measures require successful implementation of the 2015 Edition CEHRT, which Kareo will achieve by January 1, 2018.

For the 2017 year, the following two activities can be implemented for bonus opportunity.

  • Implementation of use of specialist reports back to referring clinician or group to close referral loop
  • Use of decision support and standardized treatment protocols
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