Clinicians

MACRA Frequently Asked Questions

If you are a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified registered nurse anesthetist billing Medicare Part B, you must participate in the Quality Payment Program (QPP). If you are not in an Advanced Alternative Payment Model (APM), you must participate in the Merit-based Incentive Payment System (MIPS).

You may be excluded from MIPS if you are:

  • Newly-enrolled in Medicare, meaning you enrolled for the first time during the performance period;
  • You are below the low-volume threshold, meaning your Medicare Part B allowed charges are less than or equal to $90,000 a year OR you see 200 or fewer Medicare Part B patients a year; or
  • You are significantly participating in Advanced APMs, meaning you receive 25 percent of your Medicare payments or see 20 percent of your Medicare patients through an Advanced APM.

CMS estimates that 540,000 clinicians will fall below the low-volume threshold, so be sure to check your participation status on the QPP website.

MIPS consolidates three existing programs, Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Modifier (VBM), all of which will sunset at the end of 2018 when the final penalties are assessed. MIPS is made up of four performance categories, each of which will be combined to create a clinician's or group's Composite Performance Score. The categories and corresponding weights for 2017 are listed below:

  • Quality (50%)
  • Advancing Care Information (25%)
  • Clinical Practice Improvement Activities (15%)
  • Cost (10%)

Bonuses and penalties will be assessed two years after each performance period. Payment adjustments for the second performance year (2018) will be applied in 2020.

The Centers for Medicare and Medicaid Services (CMS) deemed 2017 a transition year for MIPS, allowing participating clinicians to “pick their pace.” To avoid a penalty in 2020, clinicians will have to report more quality information in 2018.

CMS finalized a performance threshold of 15 points for the 2018 performance period, an increase from the threshold of three points required in the first year of the program. Providers can reach the 15-point threshold through multiple pathways, many of which only require partial MIPS reporting. For instance, small practices could reach the performance threshold by reporting just three quality measures or one quality measure and one medium weighted improvement activity along with receiving the five-point small practice bonus. Any physician or practice could submit the maximum number of improvement activities and reach the 15-point threshold because the improvement activities performance category is worth 15 percent of the final score.

Scoring between 15 points and 69 points will allow a clinician to avoid a negative payment adjustment and may provide a slight positive payment adjustment.

The additional performance threshold for exceptional performance will remain at 70 points, the same as for the transition year. A provider whose MIPS score reaches 70 points or above will receive an additional, escalating positive adjustment ranging between 0.5 percent and 10 percent.

It is important to note that for the quality and cost categories CMS is requiring a full calendar year reporting period for 2018. However, no quality data is reported for the cost category; CMS extracts the information from claims. The performance period for improvement activities and advancing care information is a minimum of a continuous 90-day period within the calendar year up to and a full year as a maximum.

Clinicians may choose to report all of the required data for a full year. To learn what the requirements are for each performance category, refer to the chart in the “How do clinicians report their data?” question below.

Please note: Not participating in the QPP or scoring below 15 points for 2018 will result in a negative 5 percent payment reduction in 2020.