MACRA, QPP, PAMA: Part 2 for Radiologists

8-Part Series for Radiologists

Protecting your Medicare Revenue Stream in 2017-18

Part 2: Details of MACRA and the Quality Payment Program (QPP)

The Quality Payment Program (QPP) under MACRA establishes a new Medicare payment model for physicians and other providers for ambulatory services. This includes office visits, surgery and many procedures, including interventional radiology codes.

Say "Good-bye" to automatic annual Medicare increases

If you participate with Medicare, you know that you have been able to receive annual increases based on two factors:  The Sustainable Growth Rate (SGR) and the annual "doctor fix" passed by Congress in the years when the SGR might have gone down without the fix.

MACRA has now ended the SGR and has left only a 0.5% growth rate during the next few years.  This will have a huge impact on reimbursements starting in 2019 as shown by the graph below:


Histogram Graph of Sustainable Growth Curve (SGR) under Medicare 1989 to present
The Day of Automatic Fee Increases is Over!


Though the QPP is called a "voluntary program", it may impact your ability to survive as inflation and your practice overhead increases.  So if you are not a "qualifying provider", your fees will essentially be flat for the next several years.  If you are a "qualifying provider", and choose to not participate, your fees will actually go down, from 4 - 9% below this baseline.

There are two programs under QPP:

  • Merit-based Incentive Payment System (MIPS)
  • Alternative Payment Model (APM)

Most fee-for-service (FFS) providers will fall under the MIPS criteria for QPP. However, if you are a provider within an Accountable Care Organization (ACO), you may qualify under the other arm of QPP, called the Alternative Payment Model (APM)

If you are not in a group, and only read diagnostic studies, then you are most likely not impacted by MACRA. You should instead focus on the impact of PAMA in 2018 which is entirely focused on outpatient imaging studies.  We will discuss PAMA further in later segments of this series.

However, if you are an interventional radiologist, or in a group with a significant amount of revenue from interventionists, then you should not be too quick to brush off the QPP.  Unlike Meaningful Use, QPP can apply to your group if you file under a single Medicare provider number.

To know where you stand, CLICK HERE for the link to the CMS website. There you can enter your NPI and see if Medicare expects you to participate as a qualifying provider.

If you're in a Group that has data, go for the bonus...

If your group qualifies, but you personally do not, consider submitting your group data to collect bonus money.  Yes, you heard it right.  If you do at least $30,000/year in Medicare reimbursement, yet are not expected to report, you can still report your data and potentially earn bonuses without risk of penalty.  Never leave money on the table for the work that you are doing.

If you are a "qualifying provider", the program is already underway.

The program took effect January 1, 2017. It allows qualifying providers three options:

  1. Do not participate – results in a 4% reduction in your Medicare reimbursements for 2019 and accelerating to 9% over four years.
  2. Partially participate – Avoid penalties, and potentially earn some bonuses
  3. Fully participate – Earn up to 4% bonus in 2019.  Subsequent bonuses will grow to 5%, 7% and 9% over subsequent years.

So if you are not prepared, we encourage you to get engaged.  Your 2019 fee schedule will be impacted by your actions between now and the end of this year.

Don't fall prey to the Dangerous Myths about QPP:

·       “I was excluded from Meaningful Use, so QPP doesn’t affect me.”

·       “This doesn’t impact me now, so I’ll deal with it later.”

·       “President Trump and Congress are repealing/replacing ObamaCare, so this is going away.”

Why Care as a Provider?

  • Major change in how physicians get paid by Medicare
  • Took effect January 1, 2017
  • What you do in 2017 greatly affects your Medicare reimbursement starting 2019 and beyond
  • 8% payment gap for 2019 between those who prepare in 2017 and those who do not
  • Actions in 2017 may make a difference of up to 18% of Medicare reimbursements by 2022

Why Care as a Practice Administrator?

  • Need to know if each physician is affected by QPP and determine best program for participation
  • Important to know what billing codes are included in the QPP
  • QPP can be filed by individuals or on behalf of a group practice under a single Medicare provider number
  • While a minimal effort can prevent penalties for 2017, more will be required for 2018 and beyond.

CLICK HERE for more immediate information about MACRA and the QPP.  Part 3 provides more detail about this program.


If you missed

Part 1: Introduction, CLICK HERE.

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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