MACRA, QPP, PAMA: Part 1 for Radiologists

8-Part Series for Radiologists:

Protecting your Medicare Revenue Stream in 2017-2018

Part 1: Introduction

 

Over the past 20 years, Radiologists have experienced a significant decrease in Medicare reimbursements.  Two governmental payment schemes may put even more of your dollars at risk.  However, they also can provide potential upside opportunities for those who best understand these two programs work. Radius LLC and MedMorph LLC have partnered to bring you this 8-part series to help explain these two programs. We hope that you will invest 10 minutes per article to read and leverage the resources. Each article will also link to more resources at HealthITAccelerator.com and at CMS.gov.  This information may help you prevent unnecessary losses or even earn a bonus.

MACRA and the  Quality Payment Program (QPP)

The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) took effect January 1, 2017 as Medicare’s Quality Payment Program (QPP). QPP affects physician reimbursement under two options: Merit-based Incentive Payment System (MIPS) and Alternate Payment Models (APM).

MACRA also is a statutory regulation. The Senate passed this bill with a bipartisan 92-8 vote. The Medicare part of the bill ended the annual Sustainable Growth Rate (SGR) formula for physician Medicare reimbursement (which you may remember as the annual “doctor fix”).

MACRA continues the shift from volume to value (see above) on the outpatient side as it creates a framework for rewarding providers for giving “better care” in their practices/clinics.  It also combines several earlier programs such as:

  • Physician Quality Reporting System (PQRS)
  • Meaningful Use EMR incentive payments (MU)
  • Value Modifier (VM or Value-based Payment Modifier).

While the QPP seems directed at “office-based providers” many radiologists will fall under the QPP if they meet certain criteria:

  • Bill Medicare over $30,000 a year.
  • Perform over 100 office visits per year or do over 100 qualifying CPT procedures
    • Interventional radiologists and those performing pain management procedures should pay particular attention to this.
  • Belong to a group with a significant number of interventional radiologists.
  • Qualify for an Alternative Payment Model, such as participating in Accountable Care Organizations (ACOs)

You may want to visit our glossary of MACRA/QPP terms to begin to understand this law.

Throughout this series we will educate you on this program as well as introduce you to PAMA, a law that will impact all outpatient radiology practices who provide Medicare Services.

PAMA and the Appropriate Use Criteria (AUC)

The Protecting Access to Medicare Act of 2014 (PAMA) will take effect on January 1, 2018.  It requires clinical decision support systems to confirm Appropriate Use Criteria (AUCs) on ambulatory (outpatient), non-emergent advanced imaging studies such as MRI, CT and PET scans. The bizarre feature of this law is that it penalizes radiologists and their imaging center if their referring physicians do not use a clinical decision support system (CDSS) to assess the appropriateness for each advanced imaging study they order.

So, if the referring physician does not use a CDSS tool when ordering, the radiologist does not get paid. 

Since radiologists cannot order the tests they read, they cannot be the ones ordering the test. So this puts the ordering physicians and the radiologists at financial odds, with the patient in the middle.

Unlike the overwhelming bipartisan vote on MACRA, the Senate passed PAMA on 3/31/2014 with a 64-35 vote. This statutory regulation impacts a large basket of providers and services including skilled nursing facilities and physicians’ offices in regards to their ordering of imaging studies and laboratory tests.


For radiology, PAMA takes effect on January 1, 2018, though CMS proposed some changes in July 2017 to move implementation to January 1, 2019, eliminate penalties in 2019, and let ordering physicians receive incentives under MIPS (the Merit-based Incentive Payment System under QPP/MACRA).  This would be welcome news if they approve.  We will have more on PAMA in Parts 3 and 4.

So for radiologists, it is important that you understand and follow the developments under these two federal laws and their Medicare programs.  We will strive to make it easier through this series.


This 8-part series comes to you from Radius, LLC, a radiology services company and MedMorph LLC, healthcare IT consulting company.

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