Simplified Answers to “What is MACRA?”

The healthcare industry in the US is rather a mess right now. In fact it is a big mess with politicians fighting over which healthcare bill to pass and premiums rising and quality of care dropping. The maternal mortality rate in the US is almost 20% higher than that of Italy's an there is more statistics to show the deterioration. Sadly, MACRA which is expected to make things better is currently doing more harm than good. The Macra Metrics is all over the place with doctors as they can’t understand it fully or come to a comprehensive conclusion on what needs to be done.

In an attempt to solve this mess one step at a time, simplifying the rules and expectation by addressing the MACRA frequently asked questions is a good start. Some frequently asked questions are answered below

What is MACRA

  • The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA created the Quality Payment Program that:
  • Repeals the Sustainable Growth Rate formula
  • Changes the way that Medicare rewards clinicians for value over volume
  • Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
  • Gives bonus payments for participation in eligible alternative payment models (APMs)
  • MACRA also required us to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019.

Read more here

Who is required to participate?

MACRA is not just for Physicians. It’s also required for Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and groups that include clinicians who bill under Part B. Individuals who bill Medicare more than $30,000 and anyone already part of an Advanced APM will also participate.

What if I don’t report at all?

Those who don’t report will not only have to pay the 4% fine but also face potential impact on their reimbursement, future job search efforts and lost reputation with potential patients.

If I work in a large organization, do I need to worry about preparing for MACRA?


Should I report as an individual or group?

MACRA defines a group as a single Taxpayer Identification Number (TIN) with two or more MIPS eligible clinicians, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN. If you don’t fit this requirement then you should report as an individual.

What about multi-specialty practices, should they report as a group?

Most practices find it beneficial to report as a group as reporting individually will be a tedious process. Reporting as a group makes it relatively easier to achieve measures, such as care coordination, that require effective communication among providers, patients, and specialists. Everybody can participate in this.

Why is MACRA necessary?

MACRA is necessary because systems in the past subject doctors to negative payment adjustments and unfair penalties. MACRA stabilizes the reimbursement landscape and regularizes penalties reducing it from 11%(which is outrageous) to 4%.

How do payments work?

MIPS will be eligible for positive or negative Medicare Part B payment adjustments that start at 4% and gradually increase to 9%. This payment method will start in 2019 and go on till 2022. This payment distribution will be made on a  sliding scale and will not be affected by budget. I.e it will be budget neutral. Instead, the payment adjustment will be made on a sliding scale and based on:

  • Physicians with a final score at the threshold will receive a neutral payment adjustment.
  • Physicians with a final score above the threshold will receive a positive payment adjustment on each Medicare Part B claim in the payment year.
  • Physicians with a final score below the threshold will receive a negative payment adjustment on each Medicare Part B claim in the payment year.
  • Physicians with a final score in the lowest quartile will automatically be adjusted to the maximum negative adjustment on each Medicare Part B claim in the payment year.