Learn the Language of MACRA and the QPP...
Glossary of Terms for MACRA and the CMS Quality Payment Program
The Quality Payment Program (QPP) became effective on January 1, 2017 and may impact your Medicare reimbursements in 2019 and beyond. This MACRA QPP Glossary of Terms may be helpful for you as you navigate this new payment program.
If you are a physician and don't know if it impacts you, click the link to CMS.gov below:
Accountable Care Organization (ACO):
- An organization that provides care to a population of patients and shares financial risk with the plan administrator (payor). Goal is to improve care, improve access, lower cost (provide better overall value). There are two types of ACOs under Medicare. The Pioneer ACOs committed to a three-year program to equally share upside and downside financial risk with Medicare. Providers in most other ACOs have a limit to the downside risk and the upside benefit.
ACI - See Advancing Care Information (below)
ACO - See Accountable Care Organization (above)
Advancing Care Information (ACI):
- Category under MIPS that replaces Meaningful Use (MU) certification for outpatient Medicare providers. (NOTE: MU is still in effect for hospital and for outpatient Medicaid).
Alternative Payment Models (APMs):
- One of the two major pathways for reimbursement through Medicare’s Quality Payment Program. Has several options within the pathway based on programs such as ACO’s, PCMH, Oncology, End-stage Renal Disease (ESRD) and two-tier payment models. Successful participants not only share on cost containment efforts, but can earn up to 4% additionally for high-performance.
- CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award
- MSSP (Medicare Shared Saving Program)
- Demonstration under the Health Care Quality Demonstration Program
- Demonstration required by Federal Law.
MACRA does not change how any particular APM rewards value. APM participants who are not Qualifying APM Participants (QP, as defined by APM) will receive favorable scoring under MIPS (i.e. not be penalized, but not necessarily rewarded). Only some of these APMs will be eligible APMs (e.g. one-sided MSSP do not qualify).
Those who participate in the most advanced APMs may be determined to be qualifying APM participants (QP) and:
- Are not subject to MIPS
- Receive 5% lump sum bonus payments for years 2019-2024.
- Receive a higher fee schedule update for 2026 and onward.
Models of APMs include:
- Comprehensive ESRD Care (CEC, 2-sided risk)
- Comprehensive Primary Care Plus (CPC+)
- Next Generation ACO Model
- Shared Savings Program – Track 2 (60%)
- Shared Savings Program – Track 3 (70%)
- Oncology Care Model (OCM 2-sided risk)
Three APM requirements for 2017:
- Must use a certified Electronic Health Record (EHR)
- Must be paid on quality measures in the quality category of MIPS (see MIPS and Quality)
- Must be either an accredited PCMH or a risk-sharing ACO-like arrangement.
APMs - See Alternative Payment Models (above)
Centers for Medicare and Medicaid (CMS):
- This is the federal center under the Department of Health and Human Services (HHS) that administers the Medicare and Medicaid health programs at the federal level.
Children's Health Insurance Program (CHIP):
- Children’s Health Insurance Program (federal). Federal program that provides health insurance coverage to children in low-income households not covered by Medicaid.
CHIP - See Children's Health Insurance Program (above)
Clinical Practice Improvement Activities (CPIA):
- Process improvement activities under MIPS. Currently there are 90 choices within 9 groups of activities and clinicians can innovate to create opportunities to earn points in this category.
CMS - See Centers for Medicare and Medicaid (above)
CPIA - See Clinical Practice Improvement Activities (above)
- Common Procedural Terminology codes. A system of codes licensed by the American Medical Association (AMA). Providers use CPT codes to file claims for encounters (office, hospital, etc.). and procedures/operations. Under QPP, Medicare publishes annually a list of codes that define you as an Eligible Clinician.
Designated Rural Areas:
- Federally-designated rural areas. These providers have lower MIPS requirements (20 points rather than 40 points) in 2017.
Eligible Clinicians (under QPP):
- Providers who are beyond their first year of CMS participation, receive at least $30,000 in reimbursement, and see at least 100 patients within the selected CPT codes that qualify under QPP. See Provider below for a list of licenses that define eligible clinicians.
- Tradition payment model in which providers are paid for the number of specific encounters/procedures performed. Submission for reimbursement is codified through CPT (Common Procedural Terminology) codes, as licensed through the American Medical Association (AMA)
FFS - See Fee-for-Service (above)
Health Professional Shortage Areas (HPSA):
- Federally-designed rural, remote areas in which a shortage of health care providers exists. These providers have lower MIPS requirements (20 points rather than 40 points) in 2017.
HPSA - See Health Professional Shortage Areas (above)
- Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). This is the actual statute (law) passed by Congress. The Quality Payment Program (QPP) is Medicare's implementation of MACRA. The law also provided funding to reauthorize the Children's Health Insurance Program (CHIP).
Meaningful Use (MU):
- EMR Incentive program set up under HITECH, part of the American Recovery and Reinvestment Act of 2009 (the “Stimulus”). Now rolled up under APM and MIPS (the latter as ACI or Advancing Care information.).
Meaningful use remains in effect for eligible hospitals as well as providers in the Medicaid program.
Medicare Shared Savings Programs (MSSP):
- A group of programs under Medicare in which the providers and CMS share savings achieved by reducing the cost of care over a year to a population of patients.
Merit-based Payment System (MIPS):
- One of the two major pathways for reimbursement through Medicare’s Quality Payment Program. Defines four categories of participation, each having points to earn. At end of year, provides submit supporting data to CMS and either earn rewards or penalties. Has four categories, each with its own point system and definitions:
- Quality (replaces PQRS)
- Advancing Care Information (replaces MU for Medicare outpatient)
- Clinical Practice Improvement Activities (CPIA, 90 choices under 9 groups)
- Cost/Resource Use (replaces the Value-based Modifier)
2017 MIPS Category Weighting for reporting:
- 60% Quality
- 25% ACI
- 15% CPIA
Cost is determined by CMS and requires no report in 2017.
MIPS - See Merit-based Payment System (above)
MIPS APM Participants:
- Clinicians who plan to file under APM, but do not meet the threshold are evaluated for bonuses/penalties under MIPS by default.
MIPS at your pace:
- Ability for eligible clinicians in 2017 only to start participation either on Jan 1, 2017 or no later than October 2, 2017 to avoid penalties for 2017 which effect 2019 reimbursement. Eligible clinicians under MIPS who do not participate by Oct. 2, 2017 will have an automatic 4% Medicare payment reduction in 2019.
Four Options therefore for 2017 MIPS Participation:
- Don’t participate. Don’t collect and send any data to Medicare and take a 4% reduction on 2019 Medicare reimbursement.
- Test. Submit a minimum amount of 2017 data to Medicare and avoid any penalties in 2019.
- Partial. Submit qualifying data for Q4 2017. No penalty and may receive some bonus in 2019
- Full. Submit full year of 2017 data to Medicare and earn bonuses up to 4%.
MIPS data submission window for 2017:
- January 1 through March 31, 2018 is the window for eligible clinicians to submit 2017 MIPS data to avoid an automatic 4% payment reduction on 2019 Medicare reimbursement.
MSSP - See Medicare Shared Savings Program (above)
MU - See Meaningful Use (above)
Patient-Centered Medical Home (PCMH):
- A model (originally) for primary care in which the physician office works closely with the patient and family to coordinate safe and effective care. For the purpose of APM, Medicare qualifies that a PCMH must be federally recognized. Radiologists and some specialists may be working within a group practice within a recognized PCMH.
The Agency for Healthcare Research and Quality (AHRQ) defines the PCMH as:
An organization of primary care that delivers the core functions of health care in five functions and attributes:
- Comprehensive Care
- Coordinated Care
- Accessible Services
- Quality and Safety
Physician Quality Reporting System (PQRS):
- Prior way physicians submit quality data to the federal government.
PCMH - See Patient-Centered Medical Home (above)
PQRS - See Physician Quality Reporting System (above)
Provider (under QPP):
- Generic name for licensed professionals who can independently diagnose and prescribe. By name (degree(s) includes
- Physicians (M.D, & D.O.),
- Dentists (D.D.S. ) & D.M.D.),
- Podiatrists (D.P.M.),
- Optometrists (O.D.), and
- Doctors of Chiropractic (D.C.)
As well as:
- Physician Assistants (PA)
- Nurse Practitioners (NP)
- Clinical Nurse Specialists
- Certified Registered Nurse Anesthetists (CRNA)
- AND any clinical group that includes ONE of the professionals listed above.
QPP - See Quality Payment Program (below)
Quality Payment Program (QPP):
- Medicare’s operational program defined by MACRA to reimburse physicians based on quality/value rather than volume. This program became effective January 1, 2017. Under this "voluntary program, CMS makes reimbursement adjustments (rewards or penalties) in the second year after the patient care services occur. For example, 2019 CMS reimbursement will be adjusted based on data submitted 2018 for patient care done during 2017.
SGR - see Sustainable Growth Rate (below)
Sustainable Growth Rate (SGR):
- Congress applied the Sustainable Growth Rate formula to define (and limit) the annual rate of Medicare growth. Congress eliminated the SGR by passing the MACRA legislation which has been enacted as the QPP.
Value-based Financial Rewards:
- MIPS Bonus/Penalties to Medicare Reimbursements:
- 2017 care: +/- 4% in 2019
- 2018 care: +/- 5% in 2020
- 2019 care: +/- 7% in 2021
- 2020 care: +/- 9% in 2022 and onward
- APM-specific rewards PLUS MIPS Adjustments
Eligible APMs rewards:
- Eligible APM-specific rewards PLUS 5% lump sum bonus
- Payment scheme to replace traditional FFS or volume-based reimbursement. Providers are paid on outcomes rather than volume of patient care. Requires a shift in care delivery and the collection of clinical outcome data to support payment.
Value-based Modifier (VM):
- A value-based payment modifier to additionally reimburse expenses for certain providers in physician offices for achieving specific goals/outcomes. Now rolled up into QPP under cost/resource use.
VM - See Value-based Modifier (above)
- Another common name for Fee-for-Service (FFS) reimbursement. In FFS, physicians are rewarded for the volume of encounters/procedures with no regard to the value/success of those efforts.