American Association of Clinical Endocrinologists

Steps to Prepare Your Practice for MACRA

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on October 14, 2016 to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on Jan. 1, 2017. Under the new law, CMS has designed a new Quality Payment Program that has two paths: the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

Below are a few steps that AACE members can take to prepare your practice for the new physician payment system.

  • Learn about MACRA and decide if an APM is right for your practice. Otherwise, you will be in MIPS.
  • Assess your performance under Medicare’s current quality programs.
  • Review MIPS quality measures and reporting mechanisms.
  • Contact your EHR vendor.
  • Review the list of approved clinical practice improvement activities to determine what activities will want to report.

Step 1: Learn about MACRA and decide if an APM is right for your practice. If not, you will be paid fee-for-service with bonus payments or penalties under the new MIPS program.

To learn about MIPS and APMs, use education resources from the AACE MACRA Resource Center (https://www.aace.com/resources/endocrine-survival-toolkit), the American Medical Association

(https://www.ama-assn.org/practice-management/understanding-medicare-payment-reform-macra , and CMS (https://qpp.cms.gov/). Determine if an APM or advanced APM is an option for your practice. If you are currently in an APM and are not sure where you stand, contact your APM administrator. If an APM is not an option, you will eventually be subject to MIPS bonus payments or penalties.

Is your practice exempt from MIPS quality reporting? - Before you begin, consider whether you are exempt from MIPS participation. CMS provides an exemption for physicians from MIPS in 2017 if they are in their first year of Medicare Part B participation, part of an advanced alternative payment model, or are below the low volume threshold of $30,000 or less in annual Medicare revenue or 100 or fewer Part B enrolled Medicare beneficiaries annually.

The easiest way to comply in 2017 to avoid a payment penalty in 2019 - For the 2017 performance year, CMS is implementing a “Pick Your Pace” transition approach to quality reporting.  You can avoid the payment penalty in 2019 by reporting for one patient on one quality measure, or one clinical practice improvement activity, or the 4 required Advancing Care Information measures in 2017.  You will receive a penalty of 4% to your Medicare payments in 2019 only if you choose not to report any performance data.   If you choose to submit 90 continuous days of data to CMS during 2017 in any of the three categories included in the 2017 score (see below) you will be eligible for a small payment bonus, and if you choose to submit a full year of performance data to Medicare you will be eligible for a moderate bonus. 

  • If MIPS compliance and reporting is right for your practice, prepare to participate in the new quality program, which in 2017 includes performance measurement in the following 4 weighted categories.  For 2017, the weights associated with each category are:
  • Quality (60 percent),
  • Advancing care information (25 percent),
  • Resource use (0 percent in 2017), and
  • Clinical practice improvement activity (15 percent).
  • The resulting weighted performance category scores would be summed to create a single composite performance score from 0 to 100 in 2017. That score would then determine whether you receive a Medicare payment bonus in 2019.  In 2017, the cost performance category is “0” percent of the composite performance score.  In 2018, the cost performance category is 10% of the composite performance score and will make up 30% of the composite score in 2019 and beyond.

Again, if you choose to submit 90 continuous days of data to CMS during 2017 in any of the three categories included in the 2017 score you will be eligible for a small payment bonus, and if you choose to submit a full year of performance data to Medicare you will be eligible for a moderate bonus.

  • In 2017, the majority of physicians will fall under MIPS. For the first performance period, MIPS will apply to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, which CMS collectively refers to as “eligible clinicians.” As you learn about MIPS requirements, determine if you will report individually or as a group.
  • If you plan to transition to a new group practice, be aware that your future pay may be affected by the new group’s past performance. This is because CMS has defined a group in 2017 as a group that would consist of a single tax identification number (TIN) with two or more eligible clinicians (as identified by their individual national provider identifier [NPI]) who have reassigned their billing rights to the TIN. Because payment for any year is determined by the performance period two years previously, you should inquire about the group’s past MIPS performance. For example, if you report to MIPS in 2017 and then join a new group in 2018-19 and reassign your billing rights to its TIN, you may be subject to the new group’s 2019 MIPS incentive or penalty based on how the group performed in 2017, regardless of your MIPS performance under a different NPI/TIN in 2017.
  • If you are leaving a group during 2017, and the group participated in MIPS in that same year, you should consider how the group may address retrospective compensation/incentive in your employment agreement depending upon its 2019 MIPS incentive or penalty.

Step 2: Assess your performance under Medicare’s current quality programs.

MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and Electronic Health Record (EHR) Incentive Program (meaningful use). The transition to MIPS may be easier if you are already familiar with the current CMS quality programs. Assess your performance under these programs and as you learn about MIPS requirements, determine what changes you will have to make in your practice to meet the requirements for each MIPS category.

  • If you participate in the PQRS and VM programs, and if you have not already reviewed your reports, get to know the type of feedback CMS provides and the data it uses to assess your quality and cost performance. For the PQRS program, access your PQRS feedback report; for the VM program, access your quality and resource use report (QRUR).
  • Analyzing your feedback reports will help you prepare for the quality and resource use categories in MIPS. Consider which practice strategies you could implement to optimize performance and improve your scores in 2017. Past reports are available to you at any time; reports for the 2015 PQRS and VM performance period were released in September 2016.
  • For more information about the current CMS quality programs, visit AACE’s Socioeconomic webpage at:  https://www.aace.com/advocacy/socioeconomics

Step 3: Review MIPS quality measures and reporting mechanisms.

You may report data on quality measures for MIPS in the same way you have reported data to PQRS. However, CMS has changed some of the reporting requirements, which include increased reporting thresholds and all-payer data for certain reporting mechanisms.

  • To prepare for the quality category, review the list of approved quality measures in the MACRA final rule.
  • For the list of individual quality measures, including outcome and high priority measures, available for MIPS reporting in 2017, go to: https://qpp.cms.gov/measures/quality
  • For the list of MIPS specialty measures sets for 2017, go to:

https://www.aace.com/files/socioeconomics/finalized-mips-specialty-measure-sets.pdf

Physicians and groups will have to select their measures from either the list of all MIPS individual measures in Table A or a specialty-specific measure set in Table E (measures are the same in both tables). Take note of each quality measure’s type and data submission method.

  • Determine which reporting mechanism will best fit your practice in 2017. Start by reviewing the existing reporting methods under the PQRS program: Medicare Part B claims, registry, qualified clinical data registry (QCDR), EHR, web-interface (for groups with 25 or more) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.
    The quality category will be similar to PQRS. In 2017 to be eligible for a moderate bonus payment, physicians are required to report on 6 measures or a specialty measure set, one of which must an outcome measure or, if no outcome measures are available, a high priority measure. 
  • When selecting the measures you will report, review the data completeness criteria for each reporting mechanism; select your measures and review each measure’s benchmark, specifications, and documentation requirements. In selecting measures to report, keep in mind that simply reporting data on quality measures will not be sufficient to earn a high score. Reporting is necessary, but how well you perform on each quality measure is what will control your score. To optimize performance, align care plans, target care delivery, and/or redesign clinical workflows and train your staff so that everyone on your care team is on board to meet each quality measure in 2017.
  • Prepare your practice for potential audits. CMS intends to selectively audit physicians and other eligible clinicians annually to conduct “data validation and auditing” of any data submitted under MIPS. Review your documentation and ensure EHR templates are used with care and that data fields in either EHR and/or paper charts clearly capture the documentation required to support each measure. Prepare to keep a record of which patients you report on per measure and performance period so that your practice can identify medical records easily if you are selected for an audit.

Step 4: Contact your EHR vendor.

The advancing care information (ACI) category of MIPS replaces the current meaningful use program that requires physicians to attest annually on meeting certain measures prescribed by CMS. Contact your EHR vendor to inquire about its MIPS readiness plan and how the vendor can help you be successful in MIPS.

  • To meet the requirements of the ACI category, an EHR is required. If you do not currently use an EHR, you will have to select, purchase, and implement an EHR. Be sure the product you select is certified.

In 2017, physicians are required to report on 4 Advancing Care Information measures in 2017, and 5 thereafter, with an additional 9 optional measures in the Performance Score, for which physicians may receive additional percentage points.  For a list of the Advancing Care Information measures, go to: https://qpp.cms.gov/measures/aci

  • If you currently use an EHR, check with your EHR vendor to ensure the product you use will be upgraded to meet the metrics required. As vendors upgrade, the product must be certified. The next upgrade will be to the 2015 certification criteria, which is optional in 2017 and required in 2018. To view the list of certified products, go to: https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/certification.html
  • There are many important considerations such as data ownership and ensuring your vendor will commit to future certification requirements.
  • Make sure you conduct a security risk analysis every year.
  • Talk to your vendor about public health reporting options.
  • If you face a significant hardship and are unable to report advancing care information measures, you can apply to have your performance category score weighted to zero.

Step 5: Explore the list of clinical practice improvement activities (CPIAs).

The CPIA category is a new performance requirement. In 2017, all physicians and groups must engage in or implement a number of activities to receive credit for the CPIA category in MIPS.

  • Physicians must attest to two, 20-point high weighted activities, four 10-point medium-weighted activities, or another combination of high and medium weighted activities equaling 40 points or more to achieve full credit in the CPIA category.
  • You are not required to perform activities in each subcategory in order to receive the highest possible score. CMS requires that each CPIA be performed for at least 90 days during the performance period.
  • CMS has finalized more than 90 CPIAs under 9 subcategories:
  • expanded practice access
  • population management
  • care coordination
  • patient engagement
  • patient safety and practice assessment
  • participation in an APM
  • achieving health equity
  • emergency preparedness and response
  • integrated behavioral and mental health

For a list of approved CPIAs, go to: https://qpp.cms.gov/measures/ia

Physicians who participate in a nationally recognized, accredited patient-centered medical home will automatically receive full CPIA credit.

  • Identify CPIAs your practice already does and will continue to do in 2017, and which activities your practice could implement to receive credit for the first performance period. If you don’t already engage in any activity on the list, identify CPIAs that fit your practice and prepare to engage in or implement them in time for the first performance period.
  • You can report your CPIAs for MIPS credit using the following data submission mechanisms: qualified registry, QCDR, EHR, health IT vendor, attestation, and/or administrative claims.

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AACE THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS