MACRA 101: A Healthcare Provider’s Guide
Healthcare is constantly changing as new technology and legislation transform the processes that govern our industry. One of the most impactful pieces of healthcare reform to pass in recent years is the Medicare Access and CHIP Reauthorization Act (MACRA).
In short, MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into a single program called the Merit-based Incentive Payment System, or “MIPS.”
You’ve likely heard these acronyms, but you may not know what they mean. To help you understand the law and its requirements, let’s unpack some of the terms you may come across as you explore the new Medicare reimbursement schedule.
MACRA (Medicare Access and CHIP Reauthorization Act of 2015) replaces the previous Medicare reimbursement schedule with a new pay-for-performance program that’s focused on quality, value, and accountability. MACRA is a new payment framework that rewards healthcare providers for giving better care instead of more service. MACRA gives clinicians and physicians a choice on how they want to participate: MIPS or APMs.
MIPS (Merit-Based Incentive Payment System) is the name of the new reimbursement schedule that MACRA creates. Using a composite performance score, participating individuals receive payment based on their activity in the form of a bonus, a penalty, or no payment adjustment. The MIP system is a quantity-based way of receiving payment.
APMs (Alternative Payment Models) are new approaches to paying for medical care through Medicare that incentivizes quality and value. Additionally, an Advanced APM allows for more compensation based on the risk that the clinician or physician takes based on the outcome of the patient. APM is a quality-based way of receiving payments, which uses a Value-Modifier (VM) to determine the fee adjustment.
QPs or EPs (Qualified Professional / Eligible Professional) are clinicians and physicians who participate (QP) or are eligible to participate (EP) in Advanced APM’s.
PQRS (Physician Quality Reporting System) is a quality reporting program that encourages individual EPs to report information on the quality of their own care to Medicare. PQRS are taken into consideration for MIPS reimbursement.
VM (Value-Modifier), also known as PVBM (Physician Value-Based Modifier) is the program that actively measures the quality and cost of care provided to Medicare customers by physicians and clinicians. The VM program makes an adjustment made on a per claim basis to Medicare payments for items and services under the Medicare fee schedule.
There is a lot to know about MACRA, but the bottom line is: this reform allows for better payment options and creates a more streamlined process, resulting in better care.