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  • MACRA Compliance Step 1: Check Your MIPS Eligibility

MACRA Compliance Step 1: Check Your MIPS Eligibility

Get ready — MACRA is definitely going live Jan. 1, and will most certainly have a huge impact on your claims payments. Before you jump on the MACRA bandwagon, you need to make sure that the program really applies to you.

The Centers for Medicare and Medicaid Services (CMS) recently announced that it would release the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) by Nov.

CMS has been very specific regarding who is eligible to take part in the Merit-Based Incentive Payment Program (MIPS) — which is a component of MACRA. The preliminary rule stated that the following healthcare providers who submit Medicare Part B services ARE included:

  • Physicians (MD, DO, DPM, etc.)
  • Physician Assistants (PA)
  • Nurse Practitioners (NP)
  • Clinical Nurse Specialists (CNS)
  • Certified Registered Nurse Anesthetists (CRNA)

That means that providers NOT on the above list are currently excluded from MIPS, such as physical therapists, dietitians, clinical psychologists, clinical social workers and occupational therapists, among others.

MACRA legislation allows CMS to expand the MIPS to other types of providers beginning in 2021, but at this point we have no idea which providers they will include. So, until then, these “excluded” providers will be paid as they currently are through 2018, and starting in 2019 they’ll be paid entirely under the standard payment rate with no adjustments either negative or positive.

In addition to the above excluded clinicians, there are several other categories of providers who are excluded from MIPS:

  • Those providers billing Medicare for the first year. This group would start reporting MIPS data in their second year, with a payment adjustment beginning two years later.
  • Providers who have a low Medicare patient volume, which CMS defines as less than $10,000 in Medicare allowables and fewer than 100 Medicare patients.
  • Clinicians who are part of an Advanced Alternative Payment Model (APM). In these cases, excluded providers will be paid based on the terms of their APM.


Take Aways:

  • Only physicians, PAs, NPs, CNSs and CRNAs are eligible for MIPS, according the preliminary MACRA rule CMS issued earlier this year.
  • All other provider types will be paid starting in 2019 according to the standard pay rate without an adjustment (either positive or negative.
  • First year Medicare billers, low-volume providers, and those involved in APMs are exempt from MIPS.

To ensure you stay ahead of the MACRA game, and are prepared before it goes live, you can figure out your options by accessing Coding Leader’s online training session, Master MACRA to Keep Getting Paid.