MACRA Decision Tree: Your Status and Applicable MIPS Exceptions

Specifically, the decision tree will help practice administrators and practicing oncologists answer the following basic questions:

  1. Am I subject to the MACRA QPP at all?
  2. Do I participate in a CMS-recognized Advanced APM?
  3. Am I a MIPS eligible clinician?
  4. Do I participate in a MIPS APM?
  5. Do other exemptions or special circumstances apply to me (includes factors such as your professional designation, number of Medicare patients seen annually, practice site(s), and the size of your practice)?
  6. Do these exemptions or special circumstances affect decisions regarding individual vs group reporting?

Ready to go?

Launch Decision Tree

Need a quick primer on MACRA-related basic concepts or acronyms? Review the list below.

  • Medicare Access & CHIP Reauthorization Act of 2015 (MACRA): Passed by Congress in 2014, it repealed the Sustainable Growth Rate (SGR) and replaced it with the Quality Payment Program (QPP), a new method of paying clinicians who bill Medicare Part B.
  • Quality Payment Program (QPP): Applies to most clinicians who bill Medicare part B, and consists of 2 tracks: 1) participation in an Advanced APM, or 2) participation in MIPS.
  • Alternative Payment Model (APM): A method of payment that links payment to performance. CMS has designated for 2017 which of these are “Advanced APMs” and which are “MIPS APMs.”
  • Advanced Alternative Payment Model (Advanced APM): A specific type of APM which links payment to performance, requires the use of certified electronic health records, and includes financial risk for the practice. Clinicians in these models are exempt from MIPS.
  • Merit-based Incentive Payment System (MIPS): Payment is still fee-for-service (FFS) but fee schedule amounts for individual clinicians or groups are adjusted based on performance 2 years prior. Performance consists of 3 categories most practices/individuals are responsible for reporting (Quality, ACI & IA). For most (but not all) practices/individuals, Quality is worth 60% of your final score, ACI is worth 25%, and IA is worth 15%. The 4th category is cost, which CMS will calculate from claims and is not factored into the overall MIPS score for the first year of MIPS (2017).
  • MIPS Alternative Payment Model (MIPS APM): A specific type of APM which does not meet the requirements for an Advanced APM and is still subject to MIPS, but receives specialized scoring considerations under MIPS.
  • Advancing Care Information category (ACI category): Previously known as the EHR Incentive Program or “Meaningful Use.”
  • Improvement Activities category (IA category): A new category under MIPS. Practices choose 1-4 activities designed to improve performance from a list provided by CMS.
  • Quality category: Previously known as PQRS. Note that while PQRS was “pay for reporting,” the Quality category in MIPS is “pay for performance.”