MACRA, QPP, PAMA: Part 3 for Radiologists

8-Part Series for Radiologists:

Protecting your Medicare Revenue Stream in 2017-2018

Part 3: How to Participate with QPP

If you are a radiologist who qualifies for Medicare's new Quality Payment Program (or in a group that qualifies), you will want to understand the basics of the program.

QPP is a framework for rewarding providers for giving "better care."

In Part 2, we discussed how QPP ends the Sustainable Growth Rate (SGR) formula and made annual adjustments in the Medicare fee schedule. QPP is a "framework" (not a prescriptive approach) of rewarding providers for improving outcomes of their patients, rather than rewarding them strictly on volume of patients seen each year.  This represents one of the shifts in healthcare know as "value-based care" rather than "volume-based care".  This is an opportunity to innovate within your radiology practice.

The QPP also combines several existing quality programs into one system.  As a radiologist or practice administrator, you may not be familiar with the older programs, since they mainly affected office-based practices rather than most imaging centers:

  • Physician Quality Reporting System (PQRS)
  • Meaningful Use (EMR incentive payments) of certified health information technology
    • While this changes Meaningful Use for Medicare, it does not for Medicaid in 2017.
  • Value Modifier (VM, or value-based payment modifier)

The four components of QPP are:

  1. Quality - Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days in 2017. (Replaces PQRS above)
  2. Clinical Practice Improvement Activities (CPIA) - Attest that you completed up to 4 improvement activities for a minimum of 90 days in 2017
  3. Advancing Care Information (ACI) - Fulfill the required measures below for a minimum of 90 days in 2017 (replaces Meaningful Use above)
    1. Security Risk Analysis
    2. e-Prescribing (e.g. most radiologists would never reach the minimum threshold for e-Prescribing)
    3. Provide Patient Access (if you belong to a group connected to an EMR, you may already have a patient portal.  Or you may have a PACS portal.)
    4. Send Summary of Care
    5. Request/Accept Summary of Care
    6. Submit up to 9 measures of your choosing for additional credit (This is where you can innovate)
  4. Cost/Resource - Will be determined by CMS in 2017 from your data, so nothing to submit for this one. (replaces the VM above)

There is a lot of flexibility in how you obtain the points for activities in your practice under each category.  There really is not a "cookie-cutter" approach to what you need to submit.  You may already have been doing some fantastic practice improvement or patient engagement activities this year that you can report for your 2017 participation.  However, you really are at risk if you don't yet know whether you need to submit for this year or not.

It is important to know if you need to submit or not in 2017

As a Radiologist, you need to know if you qualify for the program or not in 2017.  There are several points to remember:

  • If you have not participated in Medicare during the past year, you are not part of this program.
  • If you bill Medicare less than $30,000 last year, you are not part of this program.
  • If you are considered a small, underserved or rural practice, the bar has been lowered for you.  CLICK HERE.
  • Know the qualifying CPT codes.  You will quality if you use them more than 100 times this year.  CLICK HERE for LIST of CPT codes and download the Quality Measures Encounter Code Zip file.
  • Check your NPI Number for yourself and your group to see if CMS considers you eligible in 2017.  CLICK HERE for NPI Check.
  • If you are part of an Accountable Care Organization (ACO), confirm that they have a plan to submit under the Alternative Payment Model (APM) on your behalf.

And remember, if you don't quality for reporting, but have the data AND bill Medicare at least $30,000/year, consider submitting data to potentially earn a reward, while avoiding any risk of penalty.

If you qualify, select your goal for 2017 (MIPS at your pace)

Remember, if you qualify for the Quality Payment Program, there are four outcomes to your 2019 Medicare payments:

  1. If you don't submit any 2017 data, then your Medicare fee schedule for 2019 will be reduced by 4% across the board.
  2. If you submit a minimum test set of data for 2017, you will not receive a penalty or a bonus, and will only receive the standard 0.5% fee increase from the prior year.
  3. If you submit 90 days of data (partial) in 2017, you will not incur a penalty, and may even receive a neutral or positive adjustment of your fees.
  4. If you submit a full year of 2017 data, then you may earn up to a 4% Medicare payment increase.

Note that the QPP is a budget-neutral program.  This essentially means that 4% is withheld from everyone, and then is redistributed based on the levels of participations.  So everyone who does not participate is funding the bonuses for those who do.  Plus Congress provided some additional money as well to sweeten the pot for the full-year submitters and the APM participants.  Remember, as a radiologist you will do the work, regardless.

So the difference between a full participant (+ 4%) and a non-submitter ( - 4%) is 8%.  The penalties and rewards increase annually to 5% for your 2018 participation (2020 payments), 7% for your 2019 participation (2021 payments) and 9% for your 2020-2024 participation (2022-2026 payments).  That 18% difference will be a game-changer for most physicians.

You can learn more about the financial impact of QPP from an article posted earlier, "How much are doctors leaving on the table with MACRA?".  You can also visit Medicare's QPP website.  Feel free to share this post with your friends and colleagues.

We hope you join us for Part 4 as we start explaining the other law impacting radiology - PAMA.




If you missed

Part 1: Introduction, CLICK HERE.

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



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

Logo for Radius LLCLogo for MedMorph LLC, a Health IT Consulting Practice





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