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October 2016


Making Sense of the MACRA Final Rule

Part 1 of 3: Essential Concepts







For more information about this e-Alert, please contact:


Janice A. Anderson


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Ken Briggs


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Michael T. Flood


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Bruce A. Johnson


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Amy McCullough


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Ann C. McCullough


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Related eAlert:
Making Sense of the MACRA Final Rule

Part 2 of 3: Alternative payment Models

Part 3 of 3: Merit Based Payment Incentive System (MIPS)


Related Webinar:
MACRA Final Rule: Key Implications and Strategies for Success - 11.10.2016
presented by:
Bruce A. Johnson and
Sidney Welch

For more information or to register, click here.


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On Oct. 14, the Centers for Medicare & Medicaid Services (CMS) published a final rule with comment period implementing the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  The nearly 2,400 pages of regulatory text and associated commentary found in the unpublished version submitted to the Office of Management and Budget sets forth CMS' implementing regulations to replace the Medicare sustainable growth rate (SGR) formula with a new system that links Medicare fee-for-service (FFS) payments for physicians and other practitioners to care delivery, quality and value-based variables.

MACRA is viewed by many as a game changer for the delivery and payment of health care services. And since MACRA was a bipartisan piece of health care legislation, those expecting a repeal or major rewrite may be engaged in wishful thinking.

MACRA's implementation begins in earnest on Jan. 1, 2017. This is the first of a three-part series that examines various legal, operational and strategic considerations associated with the law and final rule.

This article examines certain essential concepts related to the "Quality Payment Program" (QPP) established by MACRA and implemented by CMS via the final rule, with attention to the QPP's policy objectives, alternative participation vehicles, and certain operational concerns including what physicians and other "eligible clinicians" will be subject to the law and key participation-related choices.

Separate alerts in this series examine the specific details of MACRA's participation alternatives:

  • The Merit Based Payment Incentive System (MIPS); and
  • Alternative Payment Models (APM)

Overall, this series examines MACRA and the final rule to provide practical observations and guidance to help position health care organizations for future success.

MACRA Basics and Policy Objectives

MACRA is sufficiently detailed that it’s easy to get lost in the weeds. As a practical matter, the QPP mandated by MACRA requires clinicians to participate in the evolving “value-based” payment and delivery system in a way that is intended to impact the delivery of FFS Medicare. [More...]

2017 as "Pick Your Pace" Transition Year

As noted above, the QPP will assess clinician performance and use that assessment to impact Medicare payments two years hence, such that the 2017 performance year will determine whether Medicare Part B payments to eligible clinicians who are subject to MIPS will be subject to a plus or minus 4% adjustment in 2019 and so on. [More...]

Practical and Operational Concerns -- Developing a MACRA Game Plan

The complex MACRA law and regulations include many highly technical details, so a framework and game plan can help health care organizations determine a strategy to succeed under the program. [More...]

MIPS Eligible Clinicians

Clinicians who bill under the Medicare Physician Fee Schedule (MPFS) and meet the definition of an “eligible clinician” must participate in an APM or MIPS, and those who are “MIPS eligible clinicians” are subject to potential MIPS payment adjustments. [More...]

Performance Years and Payment Years

As noted previously, the performance year for MIPS is the calendar year two years prior to the year in which the MIPS adjustment is applied – meaning performance during the 2017 performance year defines the MIPS adjustment in the 2019 payment year, performance during the 2018 performance year defines the MIPS adjustment for payment year 2020, and so on. [More...]

Individual and Group Participation and Reporting Options

The final rule generally permits MIPS eligible clinicians to report necessary data and be measured on an individual clinician or group (i.e., practice TIN) basis. Clinicians participating in an APM will be subject to the particular reporting and measurement requirements of the APM—meaning, for example, that those participating in the MSSP are required to report quality performance through the ACO and report other metrics at the practice TIN (rather than individual) level. [More...]

Additional Reporting Rules

Individual performance measures under MIPS will be updated annually. In the final rule CMS also established that where individual eligible clinicians and groups have less than 12 months of performance data to report (e.g., due to switching practices during the performance period, medical leave etc.), the individual or group will be required to report all performance data applicable to the performance period. [More...]

Projected QPP Impact – Near and Long Term

In the final rule, CMS estimates that between 592,000 and 642,000 eligible clinicians will qualify as MIPS eligible clinicians and therefore, they will be required to submit “some” data under MIPS in 2017. Only those MIPS eligible clinicians who fail to participate (i.e., fail to submit “some” data) during 2017 will be subject to the full negative 4% payment adjustment in 2019. [More...]

Observations and Additional Information

In the final rule CMS sought to balance several potentially conflicting goals and objectives... [More...]

To view or download a pdf of the full alert, please click here.

For More Information

For questions regarding this information, please contact one of the authors, a member of Polsinelli's Health Care practice, or your Polsinelli attorney.







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