TMA Five-Step Checklist for MACRA Readiness
Steps you can take NOW to prepare your practice.
The Centers for Medicare & Medicaid Services (CMS) has proposed a draft rule 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). Although the final rule will not be published until or around Nov. 1, 2016, here are some steps the Texas Medical Association recommends you take now to prepare your practice.
- 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.
- Explore the list of clinical practice improvement activities.
(Confused by all the acronyms? Check out TMA's MACRA Glossary.)
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 incentives or penalties under the new MIPS program.
To learn about MIPS and APMs, use education resources from the TMA MACRA Resource Center, your national specialty society, the American Medical Association, and CMS. 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 may be subject to MIPS incentive or penalties.
- Before you begin, consider whether you are exempt from MIPS participation. CMS proposes to exempt 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 $10,000 or less in Medicare charges and 100 or fewer Part B enrolled Medicare beneficiaries annually. Keep in mind that this criteria may change once the rule is finalized. (TMA has recommended that CMS increase the low-volume threshold to $250,000.)
- If you are not exempt, determine what a 4-percent bonus or penalty to your Medicare payment in 2019 means to your practice and bottom line. As you learn about MIPS requirements, consider your potential practice costs and effort to comply with each MIPS category in 2017. For some practices, simply taking the penalty may be less costly than attempting the compliance and reporting requirements.
- If MIPS compliance and reporting is right for your practice, prepare to participate in the new quality program, which includes performance measurement in four weighted categories:
- Quality (50 percent),
- Advancing care information (25 percent),
- Resource use (10 percent), 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, penalty, or neither in 2019.
- 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 proposed to define 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 and will include similar concepts from 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.
- The quality category will be similar to PQRS. CMS, however, proposes to score you on up to three population-based measures calculated from administrative claims in addition to the number of quality measures you are required to report. The resource use category will be similar to the VM program. CMS proposes to calculate and score resource use measures using administrative claims data only. The advancing care information category will replace the meaningful use program.
- 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 are expected to be released in September 2016.
- If you are new to the current quality programs and would like to participate in them in 2016, visit TMA's resource centers for information on how to get started. For the PQRS and VM programs, visit the TMA PQRS and VM Resource Center; for the EHR Incentive Program, visit the TMA Meaningful Use Resource Center. You can also turn to the TMF Quality Innovation Network for free education, quality consulting, and technical assistance.
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 proposed to change some of the reporting requirements, which may include increased reporting thresholds and all-payer data for certain reporting mechanisms.
- To prepare for the quality category, review the list of proposed quality measures in the MACRA proposed rule.
- See Table A on page 28399 for the list of proposed individual quality measures available for MIPS reporting in 2017.
- See Table E on page 28460 for the proposed MIPS specialty measures sets.
- See Table C on page 28447 for the proposed individual quality cross-cutting measures.
- According to the proposed rule, 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.
- Review TMA's tips on quality reporting mechanisms.
- Once CMS publishes the final list of MIPS quality measures and reporting requirements, 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 has proposed 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. TMA has numerous resources to help practices with selection.
- 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. View the list of certified products here.
- Read TMA's white paper on contracting with EHR vendors. There are many important considerations such as data ownership and ensuring your vendor will commit to future certification requirements.
- Review the current meaningful use metrics. While there will be slight differences in the final rule, the current measures are a good place to start to understand what is expected. Visit the TMA Meaningful Use Resource Center for more information.
- Make sure you conduct a security risk analysis every year.
- Talk to your vendor about public health reporting options.
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. In the MACRA law, CPIA subcategories include expanded access, population management, care coordination, patient engagement, patient safety and practice assessment, and transition to or participation in an APM. CMS has also proposed three additional subcategories: achieving health equity, emergency preparedness, and response, and integrated behavioral and mental health.
- Physicians who participate in a nationally recognized, accredited patient-centered medical home will automatically receive full CPIA credit.
- The required number of CPIAs will vary from one to six depending on each CPIA's weight and your practice model, size, and location. You will not be required to perform activities in each subcategory in order to receive the highest possible score. CMS has proposed that each CPIA be performed for at least 90 days during the performance period.
- To prepare for the CPIA category, see Table H in the MACRA proposed rule to review activities in the proposed "CPIA Inventory" on page 28570. Because CMS has proposed to assign points based on weights, take note of each CPIA’s proposed weight. At this time, CMS has proposed about 94 CPIAs and may add more when the rule is finalized.
- 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.
- To report your CPIAs for MIPS credit, CMS has proposed the following data submission mechanisms: qualified registry, QCDR, EHR, health IT vendor, attestation, and/or administrative claims.
- Once the final rule is published, review all requirements and submission mechanisms, select your activities from the complete CPIA Inventory, and prepare to engage in or implement CPIAs according to the requirements. Additionally, make sure you have documented policies and procedures in place to document CPIAs you are already doing or plan to do in the future. Refer to the TMA guide on policies and procedures or contact TMA Practice Consulting.
NOTICE: This Texas Medical Association (TMA) publication was designed to provide general information and is not intended to provide advice on any specific legal matter or professional service. This information including legal forms should NOT be considered legal advice, and receipt of it does not create an attorney-client relationship. This is not a substitute for the advice of an attorney.
The information and opinions presented as part of this publication should not be used or referred to as primary legal sources, nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases.
Although TMA has attempted to present materials that are accurate and useful, some material may be outdated, and the User shall not hold liable TMA for any negligence, inaccuracy, error, or omission, regardless of cause.
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TMA Convenes Expert Panel to Tackle Zika
TMA is working to get ahead of this year's highest-profile potential public health threat with the formation of a workgroup to strategize prevention and response to Zika virus disease.
TMA formed the workgroup to give experts a forum to share what they're seeing in the field with regard to Zika, and to discuss issues and concerns surrounding the disease. The workgroup will help TMA provide relevant information to physicians about Zika. TMA drew physicians from its various boards, councils, and committees to form the group. David Lakey, MD, chief medical officer and associate vice chancellor for population health in The University of Texas System and former commissioner of the Texas Department of State Health Services (DSHS), is the workgroup's chair.
During the group's most recent conference call meeting on July 7, the discussion included challenges with testing, reporting, and referral; emerging shortages at blood banks as a result of bans on donors who had traveled to Zika-infested areas; and potential TMA activities to help physicians and the public prevent and stop Zika. Group members and consultants also discussed the resources on the DSHS Zika website, www.texaszika.org, and the resource site for the state's Task Force on Infectious Disease Preparedness and Response, txidr.org.
"I heard a real desire by physicians to be involved with confronting this major public health event," Dr. Lakey said. "All of us are learning what that means, and I heard a desire to help the state to identify and improve the specific components of that public health response — specifically, trying to improve the availability of testing and surveillance activities in Texas and preparing for potential blood shortages that could occur. Those are critical components of the response."
Improving testing capabilities, he said, requires ongoing communication "to make sure that the system is easily understood, and the guidelines are easily understood and available to physicians," as well as increased availability of testing in Texas laboratories.
Bites from the Aedes aegypti mosquito species are the primary transmission avenue for Zika virus. The disease also can be transmitted sexually. Zika poses a particular threat to fetuses, who can develop microcephaly and other birth defects if the fetus' mother becomes infected with the disease.
The United States has had no confirmed cases of local transmission by mosquito during the current epidemic, but as of July 6 had 1,132 travel-associated cases and one laboratory-associated case, according to the Centers for Disease Control and Prevention.
As of July 7, Texas had 55 reported cases of Zika virus disease, according to DSHS. Travelers who were infected abroad and were diagnosed upon their return home accounted for all but one of those cases. The remaining case involved a Dallas County resident who had sexual contact with someone who acquired Zika while traveling abroad.
TMA and the Texas Association of Obstetricians and Gynecologists have prepared guidance for physicians on screening for and talking to patients about Zika.
Dr. Lakey, who is also the chair of TMA's Council on Science and Public Health, will take part in a panel discussion on Zika at the TMA 2016 Fall Conference, Sept. 23-24, at the Hyatt Regency Lost Pines.
How Will Value-Based Modifier Affect Your 2017 Medicare Payments?
MACRA's not here yet, but VM still is. Are you ready?
As TMA fights to improve the draft rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA), you need to remember that the old Medicare quality measurement laws are still in place for now. That includes the Value-Based Payment Modifier (VM) program. Your VM scores for 2016 will affect your Medicare payments in 2017.
The Centers for Medicare & Medicaid Services (CMS) makes quality and resource use reports (QRURs) available for physicians to compare the clinical care their patients receive to the average care and costs of other physicians' Medicare patients. QRURs are similar to report cards. Reviewing and learning to understand the QRURs now will help physicians and groups find out where they need to improve.
QRURs are generated for all physicians and groups nationwide, as identified by their taxpayer identification number (TIN). These reports are confidential. QRURs can be used to see how your practice compares with others caring for Medicare patients. Recently, the 2015 Mid-Year QRURs were released; the 2015 Annual QRURs will be released this fall. The mid-year report includes data from July 2014 through June 2015 and is provided for informational purposes only. The annual QRUR will include data from all of calendar year 2015, which is the performance period used to calculate your VM score. That score determines whether you will receive a Medicare payment bonus, penalty, or neither in 2017. Visit the CMS website to learn more about the VM and how to access your QRURs.
The TMF Quality Innovation Network is hosting a QRUR webinar Tuesday, July 26, 12:30-1:30 CT. "Secrets Revealed: Improving Your Quality Resource Use Reports Using CMS Benchmarks" will provide more information about achieving VM financial incentives by drilling down into the components of a health system's QRURs, identifying quality and cost improvement areas, and using benchmarks from CMS. Physician practices and physician and hospital quality improvement staff are encouraged to attend this presentation by Adrian Nedelcut, quality improvement manager at The University of Texas Health Science Center at Tyler.
Register today. Space is limited.
Don’t Neglect These Tropical Diseases
The Texas Department of State Health Services (DSHS) invites you to a live webinar on "neglected tropical diseases" in Texas. The webinar will cover ascariasis, Chagas disease, cysticercosis, dengue, echinococcosis, fascioliasis, hookworm, leishmaniasis, paragonimiasis, taeniasis, and trichuriasis.
The webinar, scheduled for 11 am CT on Thursday, July 28, is designed to heighten awareness among physicians about these reportable (but relatively rare) conditions. Please register online.
The presenter is Keeley Morris, MPH, an epidemiologist who specializes in high-consequence infectious disease at Texas DSHS. She will cover risk factors, clinical presentation, and laboratory testing for the diseases.
The program also will cover the progress DSHS has made in implementing House Bill 2055 from the 2015 Texas Legislature, which required the state to establish a surveillance program for emerging and neglected tropical diseases in Texas.
Continuing medical education credit will not be offered for this hour-long presentation.
This Month in Texas Medicine
The July issue of Texas Medicine features a cover story on Medicaid's Vendor Drug Program, which is under examination by the Texas Legislature. TMA's Physicians Medicaid Congress is seizing the opportunity to call for an administrative overhaul of a drug benefit physicians describe as unnecessarily complicated and confusing. In the issue, you'll also find a profile of TMA Board Trustee Dan McCoy, MD, new president of Blue Cross and Blue Shield of Texas, and information about Texas' right-to-try law, TMA's new MACRA Resource Center, and proposed Texas Medical Board rules for call coverage agreements.
Click to launch the digital edition in a new window.
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Deadlines for Doctors
TMA's Deadlines for Doctors alerts you and your staff to upcoming state and federal compliance timelines and offers information on key health policy issues that impact your practice.
Medicaid Reenrollment Deadline
TMA Education Center
The TMA Education Center offers convenient, one-stop access to the continuing medical education Texas physicians need. TMA's practice management, cancer, and physician health courses are now easier than ever to find online.
E&M Coding Made Easy Workshop
E&M Services From the Physician Perspective
Medical Records: Most Wanted Answers
Conferences and Events
TMA Fall Conference 2016
Hyatt Regency Lost Pines
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