Your 2020 Guide to MACRA

May 4, 2020 by Antonio Arias, MBA, CHBME

Topics: Meaningful Use Stage 2, Practice Management, Medical Billing Company


In the increasingly value-based world of healthcare, providers’ success will hinge on their quality of service – not their fees and volume. The latest driver of the “value-first” evolution is the Medicare Access and CHIP Reauthorization Act of 2015, which is more commonly known by the acronym MACRA. After several years of anxiety on the part of healthcare practices scrambling to prepare for the changes, MACRA finally went into full effect on January 1, 2020. Here’s a look at how the law got to this point and what it will mean for practices going forward.

What is MACRA?

Like many healthcare-related acts passed by Congress, the legislation laid out broad goals and left it to the Department of Health and Human Services (HHS) and its many sub-agencies to sort out all the details. In 2016, the Centers for Medicare & Medicaid Services (CMS) released the rules for MACRA, which repealed the wildly unpopular Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaced it with a new value-based reimbursement system called the Quality Payment Program (QPP). 

The QPP consisted of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). One of the primary goals of the MIPS program was to sunset a series of legacy programs and incorporate them into the same reporting methodology. These programs included: the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (Value Modifier), and the Medicare EHR Incentive Program (better known as Meaningful Use or MU).

Under the new MIPS guidelines, practices are scored under four categories to assess whether or not they are delivering more patient-oriented value-based care. The categories include quality, cost, promoting interoperability, and improvement activities. This new methodology was designed to reward clinicians for delivering value over pure volume. The Advanced APM program allots further bonus payments (up to five percent) to providers who participate in alternative payment models. There are four APMs laid out in MACRA: accountable care organizations (ACO), bundled payment models, the Medicare Shared Savings Program (MSSP), and patient-centered medical homes (PCMH).

The Slow Rollout of MACRA

Since CMS recognized that not all practices were prepared to meet the new reporting requirements, the agency decided to roll the program out slowly over a period of three years. For 2017, eligible clinicians were given several options for the first year of the staged rollout, each of which required a different level of reporting. By participating in MACRA reporting, there was a potential to qualify for bonus payments in 2019. Practices that did not choose to participate in any way were given a payment penalty for 2019, which strongly incentivized them to prepare for MACRA’s new guidelines.

This transition period essentially allowed providers to report at their own pace for that year, helping them shift into the change without bearing as heavy a reporting burden.

Forward-thinking practices capitalized on that opportunity to take a closer look at their tech toolset to ensure they had the functionality and support required to successfully manage the MIPS aspect of MACRA. Their chief consideration was whether their electronic health records (EHR) were set up to collect the quality data that would impact reimbursements and make that data easy to review, digest, and report.

Tips for Adjusting to MACRA in 2020

Now that 2020 has arrived and MACRA is fully implemented, healthcare practices are trying to position themselves to meet the law’s requirements while also positioning themselves for future success. According to CMS data, clinician participation rates increased significantly in 2018 and that 98% of eligible MIPS participants would receive a positive payment adjustment in 2020. 

On the downside, the actual payouts have proved disappointing thus far. That’s because MACRA was designed to be budget-neutral, with payment bonuses coming from negative payment adjustments given to providers who failed to meet performance thresholds. Providers who achieved a maximum MIPS score in 2018 will receive only a 1.68% positive adjustment in 2020. This has already led some healthcare advocacy groups to call upon Congress to reconsider the incentive program’s funding design.

In the meantime, there are a few steps healthcare practices can take to get a better handle on their reporting:

1. Embrace the Change

MACRA compliance may be complex and challenging in practice, but it creates a big-picture advantage for providers over the long run. By replacing the Medicare sustainable growth rate formula, physicians now have the ability to create their own conversion rate based on their MACRA score. Difficult as the requirements may be, they ultimately give physicians greater control over their fee schedules.

2. Involve IT

Thorough MACRA reporting requires a joint effort between IT and administrative resources to successfully combine clinical, financial, and operational data. Practices must engage the people in their organization with the technical knowledge necessary to extract the right data, then integrate it properly to meet the right criteria for reporting paths.

3. Focus on Patients

While it’s easy to get lost in the reporting details of the QPP, practices need to keep in mind that the entire point of the program is to emphasize quality care. If healthcare practices focus on creating a culture of quality, providing optimal care, and also meeting the specifics of the programs, they will be well-positioned for a patient-centric (and profitable) MACRA future.

4. Think Beyond Your Practice

The goal of MACRA was to shift the focus of healthcare providers to patient outcomes. Effective patient care is not a series of isolated treatments, but rather an ongoing process working toward a specific result. That means that healthcare practices need to think beyond their own offices and understand what happens across the healthcare system. Accurate and accessible data is central to this focus, so it’s critical that practices modernize their technology and data infrastructure to improve interoperability and help patients get the treatments they need no matter where they go.

5. Optimize Your Billing

Keeping detailed billing records is absolutely essential for filing successful reimbursement claims to Medicare and the major insurance companies. The new focus on outcome-based care has made it more important than ever for practices to demonstrate what treatments were administered, when they were given, and why they were deemed necessary. Working with a medical billing provider that understands the details of coding and knows how to best streamline the billing process can help a healthcare practice stay focused on delivering the quality care that will improve their MIPS score (and improve patient outcomes) rather than getting overwhelmed in paperwork.

Meeting MACRA Guidelines with NCG Medical

With over forty years of experience helping healthcare practices meet several generations of government medical billing standards, NCG Medical has the knowledge and technology solutions to get your practice ahead of the curve when it comes to MACRA in 2020 and beyond. Our team can help streamline your coding and billing to improve revenue cycle management and provide expert guidance for building the EHR system that will put you on a sustained path toward true interoperability. To learn more about our services, contact our team today for a consultation.

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