The Federal Government felt they needed to change the way that providers care for, and interact with, their Medicare patients. The goal being to improve patient outcomes with less healthcare cost. Instead of being reimbursed solely on codes and number of services billed, providers will also be “graded” based on the quality of care that they provide.

This is the mission of MACRA  

MACRA, The Medicare Access and CHIP Re-Authorization Act, was signed into law in 2015 but will not be implemented until 2019.

This is a bit misleading

All of the changes to reimbursement, both positive or negative, will not start until 2019. However, the performance data that determines how a provider will be reimbursed in 2019, is based on data collected in 2017.

Essentially, what a provider does in 2017 totally affects how they will be paid in 2019.

The old method of determining reimbursement included components of Meaningful Use (MU), Electronic Health Record Incentive Program, Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) program and Sustainable Growth (SG). 

The new method of determining reimbursement combines all of these into one Merit-Based Incentive Payment System (MIPS).

Eligible Professionals (EPs), this includes physicians, practitioners and therapists (some of these “professionals” will be phased in somewhere between 2017-2019) will be provided with a MIPS score based on their performance.  

Starting in 2019, this score is the driving factor behind how a provider will be reimbursed for the services they provide to their Medicare patients. If a provider fails to perform as expected, they will lose money for every Medicare claim that they bill. If they perform as expected, their reimbursement for every claim will increase. Payment could range from a -4% to +4% depending on their MIPS performance score.

By now, most providers should have reviewed and selected the required number of measures from each category that best works for their particular situation. Some categories are weighed medium or high, which could help them to achieve higher scores.

The performance categories and ratings are:

  • 60% for Quality (Previously Physician Quality Reporting Systems).
  • 25% for Advancing Care Information (Previously Meaningful Use)
  • 15% for Improvement Activities

Another KEY element of this program is that a provider's MIPS performance score will aid in the creation of a unique fee schedule that will be used to determine what a provider will be reimbursed on each claim that they bill.  The key word here is unique, as similar providers, performing the same type of service, in the same general area of town, could be reimbursed completely different based on the MIPS score that was used to develop the fee schedule.

Providers that perform as expected could be paid based on a fee schedule that could result in a increase in every paid claim, up to 9%, by the year 2022. 

Providers that choose not to participate, or those with poor performance scores, could be paid based on a fee schedule that could result in a decrease in every paid claim, up to 9%, by the year 2022. 

MACRA does allow for some exemptions from participation. Those who are newly enrolled with Medicare, have Medicare billing charges less than or equal to $10,000 AND have fewer than 100 Medicare patients in one year, could be exempt for that year.

Please note that this is just a basic overview of MACRA. The guidelines are detailed and complex. Please visit for a full overview of MACRA including  participation, reporting requirements and exemption criteria. 

In a nutshell

Every eligible professional, must participate in order to ensure adequate reimbursement in 2019.

The goal is to change the way that providers interact and treat patients with a focus on identifying and controlling the conditions or symptoms that lead to poorer outcomes. Thus serving to improve a patient's overall health and quality of life as well as to decrease healthcare costs.  

Simply put, under the MACRA guidelines, failure to improve the way that care is delivered will be a financial game changer for those Eligible Professionals that choose not to embrace it.

Side note: Some providers, may opt to participate in the Alternative Payment (ARM) instead of MIPS. ARM is a shared risk program that functions totally differently than MIPS. For the purpose of this article we have focused only on the more widely used MIPS program.


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