Posts Tagged MIPS

Physicians Can Now Apply for Hardship Exception for QPP

Physicians Can Now Apply for Hardship Exception for QPP

Physicians who have insufficient internet connectivity, “extreme and uncontrollable” circumstances or lack of control over the availability of certified electronic health record technology can begin applying for a hardship exception from the Quality Payment Program (QPP) requirement. The exception is for physicians eligible to participate in the Merit-based Incentive Payment System (MIPS). Hospital-based physicians are considered

Hospital-based physicians are considered special status and do not need to apply for a 2017 hardship exception.


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Free AQAF Assistance: Transition to MACRA’s Quality Payment Program

Free AQAF Assistance: Transition to MACRA’s Quality Payment Program

The Alabama Quality Assurance Foundation (AQAF), located in Birmingham, is a nonprofit consulting firm providing quality improvement assistance to the health care provider market through contract arrangements. Part of AQAF’s contract with CMS is to provide training to clinicians on the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM). The training includes the four categories of the Quality Payment Program (QPP): quality, cost, advancing care information and clinical practice improvement activities, and the goal is to help all Alabama clinicians achieve a positive or neutral Medicare Part B Fee Schedule payment adjustment.

AQAF assists clinicians in understanding the four categories of the QPP: quality, cost, advancing care information, and clinical practice improvement activities. The goal is to help every practice choose its pace to participate so that all Alabama clinicians achieve a positive or neutral Medicare Part B Fee Schedule payment adjustment.

Technical assistance from the staff at AQAF is always FREE and available immediately by emailing, or calling toll-free Monday through Friday at 1-844-205-5540 from 8:30 a.m. to 5 p.m. CT.

For more information about QPP and to check your eligibility, visit


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Are You a Medicare Provider Without an EHR?

Are You a Medicare Provider Without an EHR?

You can still avoid the MIPS 4 percent penalty by participating this year!

In 2017 the TEST portion of MIPS allows a provider to submit one Quality measure (previously known as PQRS) for less than a 90 day period to potentially avoid a 4 percent MIPS penalty (to be incurred in 2019) on Medicare Part B claims. One example of this is G8427 – Current Medications Documented. Every office typically documents a patient’s Current Medications. If you submit this code on your claims, even if only for a short period of time, you will be participating in the test portion of MIPS and may avoid a 4 percent penalty on Medicare Part B in 2019.

Remember, you will need to do this for every TIN/NPI combination in your practice.

The graph below shows a broad overview of the current MIPS attestation guidelines. Each line gives a brief summary of the four different attestation paths an office can choose from for 2017. Based on your 2017 participation, the above information references the row with one star and explains the simple criteria required this year to easily avoid a 4 percent penalty which incurred in 2019.

Need help understanding these new MIPS requirements? Contact MediSYS today at 1 (334) 277-6201 or email questions to Our staff has been assisting practices with various CMS incentive programs since their inception. We combine years of experience with ongoing support and detailed expertise for our clients at no additional support charges.


For information on MediSYS electronic health records and practice management solutions as well as outsourcing CCM services, please contact MediSYS at and visit the website at MediSYS is an official partner with the Medical Association.


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Taking CDI Into the Physician Office Setting

Taking CDI Into the Physician Office Setting


CDI, or Clinical Documentation Improvement, is as familiar to physicians who practice in the hospital as other acronyms such as ICU, OR, ED – but in the physician office, CDI is relatively unknown. However, with the implementation of the Merit-Based Incentive Payment System, or MIPS, CDI in the physician office will become imperative.

Most physicians will fall under the MIPS provisions of MACRA, the Medicare Access and CHIP Reauthorization Act. CMS estimates that of the 1.3 million providers under MACRA, 1.2 million will be under the MIPS program. The Quality component of MIPS is familiar to most physicians, as it is similar to the previous Physician Quality Reporting System. One new aspect of MIPS, however, is the Resource Use or Cost. This component will be 10 percent of the physician’s MIPS score in 2018, increasing to 30 percent in 2019 and beyond. The Cost score will be derived from claims data and will be based on the CPT and ICD-10-CM codes billed. Correct and specific ICD-10-CM coding will be key to physician reimbursement in this model. Medicare, and other payers implementing similar reimbursement strategies expect that a patient with a certain diagnosis will incur an estimated cost. If the cost to treat the patient far exceeds the estimate, then the physician’s Resource Use/Cost score will be low – he/she will be considered to be an inefficient physician.

A specific example to illustrate this:  The physician treats a patient with diabetes. The only code he bills for this patient is E11.9 – Type 2 diabetes mellitus without complications.  However, this patient has diabetic retinopathy, diabetic neuropathy, and diabetic chronic kidney disease. The payer’s estimated annual cost for a patient with diabetes with no complications is $1,400, but this patient incurs much higher costs due to his complications.  The physician, therefore, appears to be inefficient, and his Resource Use/Cost score will suffer. The payer’s estimated cost for a patient with diabetic chronic kidney disease is $4,300. Had the physician coded as specifically as he could have, E11.319 for diabetic retinopathy, E11.40 for diabetic neuropathy, and E11.22 for diabetic chronic kidney disease, the higher cost would have been expected, and the physician would not be penalized for the care he is rendering.

One hindrance to CDI in the physician office setting is the use of electronic medical records and the implementation of “charge passing”, codes transmitting directly from the EMR into the practice billing system. Physicians may not choose the most specific, or even the most accurate, diagnosis code, but once those codes are passed onto the claim and filed to Medicare, there is no changing or correcting that information. Corrected claims will not be accepted for this purpose. Some practices use coders to review these claims before they are actually filed.  This usually does not involve 100 percent review of the documentation, but it would allow some coding errors to be caught. For example, if a coder noted the following diagnoses on the claim:  E11.9, N18.5, G62.9, he would be prompted to discuss with the physician that N18.5 – chronic kidney disease, stage 5, and G62.9 – neuropathy, are considered to be diabetic complications and should be coded as such. And if a coder is familiar with coding guidelines, understanding that certain diagnoses require additional codes, then when she notes G30.9 – Alzheimer’s disease on the claim, she can query the physician as to which additional code is appropriate, F02.80 – dementia in underlying disease without behavioral disturbance or F02.81 – dementia in underlying disease with behavioral disturbance.

This may require additional diagnosis coding training for physician office coders, and it will almost certainly require a change in mindset. Physician coders have focused on what is documented with the mantra “Not documented, not done.” But CDI requires a similar focus on seeing what is not documented, what should be there, what is likely true for that patient – and then querying the physician.

Electronic medical records have also contributed to some of the errors seen in that physician may not have been trained properly in diagnosis documentation and coding before having access to what is essentially the entire ICD-10-CM book in their EMR. The ICD-10-CM descriptions may not match the language the physician uses, although the code is correct. For example, in ICD-9-CM, the code for depression, unspecified was 311, and the description was Depressive disorder, not elsewhere classified. In ICD-10-CM, the code for depression, unspecified is F32.9, and the description is Major depressive disorder, single episode, unspecified. Physicians may not be able to identify the appropriate code without further diagnosis education. EMR vendors and office staff may try to set up shortcuts to assist the physicians in choosing the appropriate diagnosis code and create further issues. Two recent errors I have seen in my own auditing practice:  1.) physicians coding Crohn’s disease with small bowel obstruction when they intended to code for small bowel obstruction, unspecified and 2.) physicians coding psychophysiologic insomnia when they intended to code chronic insomnia. CDI in the physician office setting must include a detailed review of the ICD-10-CM code descriptions in the EMR.

CDI in the physician office setting does not have to be as formal a process as that seen in the hospital – it can be informal discussions with the physicians. It can be accomplished through real-time shadowing or end-of-day review, but it must occur before the claim is filed. A simple CDI process could look something like this:

  • Coder reviews record for correct coding based on physician documentation.
  • Coder talks with nurse and physician about code choices.
  • Coder identifies incorrect codes chosen – discovers confusing language in ICD-10 description.
  • Coder reviews with physician and makes changes in code descriptions to assist physician in most specific and correct coding.

The keys for coders will be continuing education, which may be in the form of informal chats with the physicians and clinical staff, review of ICD-10-CM guidelines and Coding Clinic guidance, review of medical policies which can be used to help guide physicians in documenting. And perhaps most importantly, respect for the physician’s priorities. The physician’s foremost interest is care of the patient, and CDI is simply helping the physician to understand that how he documents matters and providing the assistance he needs to make it so.


Medicare Quality Payment Program

Kim the Coder (also known as Kim Huey, MJ, CCS-P, PCS, CHC, CPC, CPCO, COC) works with clients to improve coding and documentation of services and to ensure compliance with Medicare and insurance company regulations. Ms. Huey is available for on-site visits for auditing and education as well as for on-the-record audits and general coding and reimbursement questions.


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Meaningful Use and the Costs of Noncompliance

Meaningful Use and the Costs of Noncompliance

It is something of an understatement to note that the U.S. health care legal landscape is currently experiencing a degree of transition and uncertainty. There is no shortage of changes to discuss, debate, and, perhaps, grow apprehensive about. One development that has been the radar of many physicians for several years now – and brought into new relief by more recent changes such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – is the Meaningful Use concept introduced by the Health Information Technology for Economic and Clinical Health (HITECH) Act.

“Meaningful Use” relates to physicians’ use of certified electronic health records (EHR) technology in the interest of interoperability and efficient electronic exchange of health information. The Centers for Medicare & Medicaid Services (CMS) offers an incentive program which offers incentive payments to eligible professionals and eligible hospitals who join and comply. Participation involves making “Meaningful Use Attestations” regarding compliance. Both compliance and noncompliance with Meaningful Use goals can represent a significant cost to physicians: compliance, as bringing a practice’s technological infrastructure up to the appropriate standards does not come cheaply; noncompliance, as those who choose not participate in CMS’s incentive program, face reductions in their Medicare and Medicaid payments. These reductions equal a 3 percent decrease in 2017.

It appears that noncompliance with Meaningful Use standards carries more of a bite than some observers may have thought. In June of 2017, the Office of the Inspector General (OIG) released a report that Medicare made hundreds of millions of dollars’ worth of incentive payments to Meaningful Use attesters who failed to meet the necessary requirements. The OIG estimated a total of approximately $730 million dollars in inappropriate payments – more than ten percent of the total payments. CMS’s blunder largely resulted from its failure to conduct adequate documentation review, thus rendering the self-attestations of professionals prone to abuse. Note, too, that CMS is not the only authority to make inappropriate EHR incentive payments: the OIG faulted Texas in August 2015 for making such wrongful payments in an amount over $15 million through its Medicaid program.

This does not, of course, amount to a windfall for the physicians who received the wrongful payments. The OIG’s recommendation to CMS includes directing CMS to recover the wrongful payments it has identified (a small sample of the total), and to seek to identify, and then recover, the rest of the inappropriately directed federal funds. As is characteristically the case, government overpayments cannot be retained by the recipient. Thus, the takeaway from CMS’s improper Meaningful Use largesse should not be an observation that the government has, up till now, not been adequately reviewing Meaningful Use documentation. Instead, it should be that one can, of course, expect such mistakes to be corrected when discovered and that it is even more important to get Meaningful Use compliance correct now. What has been done in the past by a physician may not actually have sufficed. Additionally, part of OIG’s recommendation to CMS was to educate eligible clinicians on proper Meaningful Use documentation requirements. Physicians should look for and take advantage of such education.

This need to double down on one’s Meaningful Use efforts comes at a time when the reimbursement system is shifting to MACRA. The Medicare EHR Incentive Program is no longer a standalone program –it has been combined through MACRA with the Physician Quality Reporting System and the Physician Value-based Payment Modifier into a single program, the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). Although hospital and Medicaid Meaningful Use programs are unaffected by MACRA, clinicians will make their Medicare Meaningful Use attestations through the QPP. This program still focuses on the use of Certified EHR Technology to support interoperability and healthcare quality objectives. The meaningful use measures are calculated and compensated somewhat differently under MIPS; one significant change is that a hybrid scoring system has replaced the previous all-or-nothing approach.

Although the manner of reporting Meaningful Use has changed somewhat, it has not become either less important or markedly simpler. Getting up to speed on the technological, administrative, and reporting features of establishing Meaningful Use now – when there is some clemency as far as timing goes worked into the transition period – is certainly advisable. The need to establish the goals of interoperability, efficiency, and care coordination that Meaningful Use seeks to advance is a need that is unlikely to diminish. The fact that CMS is now beginning to seek hundreds of millions of dollars in wrongful incentive payments only highlights that Meaningful Use compliance is an issue worth following in the always changing health care landscape.

Chris Thompson is an attorney with Burr & Forman LLP. Chris practices exclusively in the firm’s Health Care Practice Group. Burr & Forman, LLP, is an official Bronze Partner with the Medical Association.

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CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

The Centers for Medicare & Medicaid Services has unveiled a 1,058-page proposed rule updating the Medicare physician payment system implemented under the Medicare Access and CHIP Reauthorization Act of 2015 with changes to make it easier for small independent and rural practices to participate.

The proposed rule would make changes in the second year of the Quality Payment Program as required by MACRA. According to a statement from CMS, the goal is to simplify the program, specifically for small, independent and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

The proposal will allow for the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or less Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes the move will exclude about 134,000 clinicians from MIPS.

American Medical Association President David Barbe released a statement commending the CMS for hearing the concerns of practicing physicians. “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country,” he wrote.

The news may come as a relief for some clinicians. In March, Healthcare Informatics found 43 percent of more than 2,000 providers stated they needed help with MACRA preparation while 30 percent said that are not prepared at all. However, after exclusions, CMS estimates 36 percent of clinicians will be eligible for participation in 2018.

The American Academy of Family Physicians stated the regulation would help improve family physicians’ ability to participate in payment reforms successfully.

“We’re pleased that, consistent with the Department of Health and Human Services’ directive, CMS has taken steps to reduce administrative and regulatory burden,” John Meigs Jr., M.D., president of AAFP, said in the statement. “We’re equally pleased that CMS agreed with the AAFP recommendations on medical homes. For example, the financial risk borne by medical homes rolls out more slowly, providing more time for family physicians to move toward full participation in the Advanced Payment Model track. Equally important are the significant steps to reduce risk for practices of all sizes in the MIPS program.”


New Quality Payment Program Resources Available

The Centers for Medicare & Medicaid Services revamped the look of the Quality Payment Program website and posted new resources to help you successfully participate in your first year of the Quality Payment Program. READ MORE

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New Quality Payment Program Resources Available

New Quality Payment Program Resources Available

The Centers for Medicare & Medicaid Services has revamped the look of the Quality Payment Program website and posted new resources to help you successfully participate in your first year of the Quality Payment Program.

CMS encourages you to visit the website to review the following new resources:

For more information, visit the Quality Payment Program website. The Quality Payment Program Service Center can also be reached at 1-866-288-8292 (TTY 1-877-715- 6222), available Monday through Friday, 8 a.m.-8 p.m. (ET) or by email at

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Questions about Your MIPS Participation Status?

Questions about Your MIPS Participation Status?

UPDATED MAY 18, 2017 — The Centers for Medicare & Medicaid Services announced all physicians required to participate in the Merit-based Incentive Payment System will receive notification of their participation status by the end of May. With the program already underway, status letters are considered by many to be long overdue.

CMS recently sent letters to 806,879 clinicians informing them they will not be evaluated under MACRA’s MIPS System for this year, according to a recent article in Modern Healthcare. Exempted doctors are those with less than $30,000 in Medicare charges and fewer than 100 unique Medicare patients per year. Physicians new to Medicare this year are also exempt. About 418,000 physicians will still need to submit MIPS data. The change came after the CMS used an updated formula to estimate providers’ Medicare revenue.

Physicians should soon receive a letter from your Medicare Administrative Contractor that processes Medicare Part B claims, providing the participation status of each MIPS clinician associated with your Taxpayer Identification Number (TIN).

Physicians should participate in MIPS in the 2017 transition year if they:

  • Bill more than $30,000 in Medicare Part B allowed charges a year and
  • Provide care for more than 100 Part B-enrolled Medicare beneficiaries a year

Starting in 2017, physicians can choose to participate in the new Quality Payment Program as a group or individually either through the MIPS or by participation in an Advanced Alternative Payment Model (APM). Physicians can earn a positive MIPS payment adjustment for 2019 if they submit 2017 data by March 31, 2018. Those who don’t submit the required data will receive a negative 4 percent payment adjustment. For more information, visit the Quality Payment Program online.

Physicians can now use an interactive tool on the Quality Payment Program website to determine if they should participate in 2017. To determine your status, enter your National Provider Identifier into the entry field on the tool and find out whether or not you should participate in MIPS this year and where to find resources. To get the latest information, visit the Quality Payment Program website. Contact the Quality Payment Program Service Center at 866-288-8292 (TTY 877-715- 6222) or email

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MACRA may sound like a word jumble with terms like MIPS, APM, QPP, ACI, CPS, VBP, and so on. Unfortunately, a majority of physicians are unaware of how this new payment system will affect their practices, so making sense of these acronyms is just the beginning.

MACRA did more than replace the Sustainable Growth Rate formula. It will soon introduce a new framework for rewarding physicians who provide higher-value care. And, it will also introduce a number of new terms physicians and their staff should become more familiar with. Following is a short list of terms every physician should know before the new payment rules take effect Jan. 1.

QPP: The Quality Payment Program. This is that new payment framework. It offers two tracks for payment: MIPS and APMs, both discussed below.

MIPS: The Merit-based Incentive Payment System. MIPS aims to align three currently independent programs — quality reporting (what physicians know now as PQRS), Advancing Care Information (now known as EHR Meaningful Use), and cost (now known as the value-based modifier) — and adds a fourth component, Improvement Activities, designed to promote practice improvement and innovation. Some physicians will be exempt from MIPS through the low-volume threshold, defined below.

APMs: Alternative payment models. Few physicians will choose this track, as many APMs are not yet available in all states. APMs typically have shared savings, flexible payment bundles and other desirable features. There are two APM participation classifications—Advanced APMs, which have their own reporting requirements and are exempt from MIPS reporting, and MIPS APMs. Read more about APMs.

Pick Your Pace: This refers to the four participation options available in the transition year, which starts Jan. 1. Physicians may elect for MIPS testing, partial MIPS reporting, full MIPS reporting or Advanced APM participation. Read more about the four options.

Low-Volume Threshold: Physicians with less than $30,000 in annual Medicare revenue or fewer than 100 Part B-enrolled Medicare beneficiaries will be exempt from all MIPS reporting. Read more about accommodations for small practices.

ACI: Advancing Care Information. This replaces Meaningful Use. It features more reasonable reporting features, including base and performance scoring, fewer measures and 90-day reporting periods. Learn more about the two ACI options.

Improvement Activities: This new component, a feature of MIPS, is intended to provide credit for practice innovations that improve access and quality of care. It features more than 90 activities across eight categories. These too make accommodations for small practices. View a full list of activities.

Reporting Option: Physicians will need to decide whether to report as an individual or as part of a group. A group is defined as two or more eligible clinicians. A physician in a group may choose to participate as an individual under MIPS.

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The Impact of MACRA

The Impact of MACRA

*Editor’s Note: Article contributed by Adele Allison, director of Provider Innovation Strategies, DST Health Solutions. Ms. Allison will be a presenter during the Medical Association’s 2017 Annual Meeting and Business Session on  April 14-15 in Montgomery.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) accelerates the pace of change in the movement toward value-based payment (VBP).1 With an effective date of Jan. 1, 2019, MACRA requires Medicare providers to choose from two defined reimbursement paths that link quality to payment: the Merit-Based Incentive Payment System (MIPS) or advanced Alternative Payment Models (APMs).2 After considering more than 4,000 comments to the proposed rule considered, CMS released the final rule on Oct. 14,3 officially rolling out the Quality Payment Program (QPP).

CMS has outlined phases for MIPS and APMs to go into effect over a timeline through 2021 and beyond. The first CMS-proposed performance reporting period begins Jan. 1, 2017 (for payment adjustments starting in 2019). Under MACRA, Medicare revenue may be adjusted upward or downward by as much as 4 percent in 2019 (based on performance in 2017) and up to 9 percent in later years.4 To respond to the rapid program launch, CMS announced in the final rule a “Pick-Your-Pace” option for 2017, allowing a range of provider quality reporting choices to comply with MACRA.5 Nevertheless, MACRA heralds a new era in provider payment where effectiveness, efficiency and performance data will determine each clinician’s economic viability. This article will explore the essential strategies providers should consider to evolve their culture and technologies towards these new value-based payments.

Impact of MACRA: The Timing

MACRA is a Medicare cost containment law grounded in quality performance. It seeks to move health care systems and providers to advance alternative payment arrangements over time, but as quickly as the industry will allow. In the mature stages, physician practices will be expected to understand and manage the risk of care associated with attributed patient populations. While population-based payment, the most advanced phase, is the desired destination, few of today’s providers are expected to be ready to assume this level of risk. Since most providers aren’t ready to take on risk, CMS expects MIPS to be the path initially most traveled by providers – predicting 761,342 clinicians to be precise.6 Yet, even MIPS is being recognized by CMS as a lofty goal in 2017.

Milestones Toward Increasing Levels of Risk-Bearing

The path forward to align value-based payment models across private and public health plans and health systems has been laid out by the recently formed Health Care Payment Learning and Action Network (HCPLAN). The HCPLAN is a public-private collaboration of health plans, providers, patients, employers, consumers, states, federal agencies and other partners seeking to accelerate the adoption of alternative payment models that reward quality and value in health care.

Among other things, the HCPLAN has defined a framework of four categories as milestones along a payment continuum. Each category moves toward increasing levels of risk-bearing, value-based care, and payment innovation (see Figure 1).7 Physicians and other clinicians can use this framework to evaluate the status of their current payer agreements in this journey. They can also use this framework to begin developing plans to evolve further along this continuum.

Four Categories of Value-Based Payment

Category 1  Traditional fee-for-service (FFS) with no link to quality or value. Category 1 represents traditional payment models typically built on fee schedules and diagnostic related groups (DRGs).

Category 2  FFS linked to measures of quality and value. Providers are paid differentially based on measures of quality, yet providers continue to receive a fee for each service. MIPS is a Category 2 payment arrangement as is the Blue Cross and Blue Shield of Alabama Quality Management Program.8

Category 3  Alternative payment built on an FFS infrastructure. Providers begin taking limited risk with alternative payment models that span across the continuum of care. A retrospective bundled payment fits in this category, as does shared savings under an Accountable Care Organization (ACO). Category 3 arrangements that include “significant but not excessive” risk-bearing qualify as advanced APMs under MACRA. Qualified participants in CMS advanced APMs will not be subject to MIPS and will be eligible to receive a 5 percent incentive payment. Available in 14 regions, CMS has elevated the expanded medical home, a risk-sharing PCMH known as the Comprehensive Primary Care Plus (CPC+), as an example of a qualifying advanced APM under MACRA.9

Category 4  This is a population-based payment. Under Category 4, payment is not triggered by clinical service delivery, but rather the payer makes a population-based payment to the provider to assume responsibility over a defined period of time. Category 4 clinicians embrace advanced risk-bearing models often across the care continuum; shared risk for an attributed patient population that may be condition-specific or global. Like more than nominal risk arrangements under Category 3, CMS will recognize Category 4 providers as QPs under advanced APMs and not subject to MIPS.

PowerPoint Presentation

CMS Outline of a “Pick-Your-Pace” Plan

Since the first MIPS performance period is set for Calendar Year 2017 and the final rule governing the details of MACRA was not released until Oct. 14, 2016, providers will have very little time to plan, prepare and implement necessary changes to succeed. In response to industry concerns and comments, CMS will allow MACRA providers to “Pick Your Pace” in 2017 under the following structure in Figure 2.10

Microsoft Word - MASA article Overview of MACRA for Providers 10

Leveraging Data for Population Health Management

Through MACRA, CMS is leading change in payment reform that will permeate to other segments of health care. Providers need to think strategically about alignment with emerging quality measures and payment structures. Today is an opportune time for providers to begin collaborating more fully with each other and health plans to achieve higher levels of measurable care and payment; and, measurement is driven by data. Providers must begin thinking about assuming collective responsibility for attributed patient populations across the health delivery system as this is where payment is heading.

To do this, practitioners should leverage combined data for population health management as a provider community. The Meaningful Use programs provided physicians and other clinicians with growing visibility into their individual patient populations. Where the payer-provider relationship is one-on-one, such as under traditional fee-for-service (FFS) contracts, individual provider technical capabilities may be sufficient to meet preliminary demands for managing patient populations. Under a growing plethora of PBP models, many different types of clinicians (primary care physicians, specialists, physician assistants, nurse practitioners, nurse specialists, dentists, physical therapists, and others) may be paid as part of a collective for a shared patient. This will be driven by composite measurements that require a view of data beyond the four walls of the individual provider enterprise.

Payers have had this aggregated data view for decades through the most foundational data-source in the U.S. – claims data. Your claims process is not just a means of getting paid. Claims are a reporting vehicle where the nuances of your patient population are communicated and assessed by a payer. More and more, payers are beginning to share this aggregated population data with providers to assist with resource management, assessment of disease burden and outcomes measurement across the care continuum.

MIPS Scoring Explained

Given that nearly 90 percent of clinicians are expected to fall under a MIPS payment arrangement, it is important to understand how scoring will occur. Essentially, a single composite score for MIPS will be based on weighted performance in four categories: quality, cost, advancing care information, and clinical practice improvement activities (see Figure 3). Ultimately, MIPS rewards and penalties will be tied to a clinician’s composite performance score, and payment will wash from low-performing to high-performing providers in a budget-neutral fashion. Maximum points can be earned under the Clinical Practice Improvement Activities (CPIA) category for official medical home status under NCQA, The Joint Commission, URAC or AAAHC; or, NCQA patient-centered specialty practice (PCSP) achievement. Additionally, the formerly known CMS Electronic Health Records (EHR) Meaningful Use program is now represented under MIPS by the Advancing Care Information composite performance score category.

Microsoft Word - MASA article Overview of MACRA for Providers 10

Where can I get help and learn more?

  1. CMS Quality Payment Program interactive website. Offers a practical overview of the new program and can assist in identifying appropriate measures and activities based on your specialty. Go to:
  2. atom Alliance and the Alabama Quality Assurance Foundation (AQAF). The CMS Quality Innovation Network (QIN)-Quality Improvement Organization (QIO) for Alabama that works on data-driven initiatives. Go to:
  3. CMS Innovation Center. Provides comprehensive information about alternative payment models being implemented and tested across the country. Go to:


A fundamental change is required to move from volume to value in payment for health care services. Today, much of health care economics is still functioning under Category 1, fee-for-service, but the roadmap towards value has been laid out under MACRA. Health care providers who understand the direction CMS is driving health care economics will be better positioned to work collaboratively with their community-based peers and payers as they move along this continuum. The stage is set for a new era of value in health care.


1   Federal Register. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Published May 9, 2016. Accessed August 12, 2016.

2   CMS. Quality Payment Program. Accessed August 25, 2016.

3   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

4   CMS. MACRA RFI Posting. Accessed August 25, 2016.

5   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

6   CMS Proposed Rule, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,, Table 63. Published May 9, 2016. Accessed August 25, 2016.

7   Health Care Payment Learning & Action Network. Accelerating and Aligning Population-Based Payment Models: Data Sharing. Published August 8, 2016. Accessed August 12, 2016.

8   BlueCross BlueShield of Alabama. Quality Management Program. Accessed September 13, 2016.

9   CMS Innovation Center. Comprehensive Primary Care Plus. Accessed September 13, 2016.

10   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

11   CMS. MIPS Scoring Methodology Overview. Accessed August 25, 2016.

Strategies to Remember...

Essential Strategy 1:  Think of your claims as a reporting vehicle where the nuances of your patient population can be communicated to a payer.

Essential Strategy 2:  Assess your payer agreements to identify the category of payment in place today. This will help you understand where you currently are in the payment continuum.

Essential Strategy 3:  Recognize payers that make up the majority of your revenue. Contact provider relations and identify that payer’s PBP strategies and timelines. This will offer you a tactical roadmap for alignment.

Essential Strategy 4:  Identify essential data-points upon which measurement will be based. Is there overlap between payers? How do you “measure up” today? Critical data identification will help you position for workflow redesign for consistent data capture.

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