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The least you need to know about MACRA

October 4, 2016
by Julie Miller, Editor in Chief
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For the last several years, the financial forecast for the Medicare program has been rather shaky. While funding isn’t in immediate danger of running out, trends indicate that insolvency could come as early as 2028. This situation has historically created a prompt for Congress, by law, to take action—specifically, to cut provider payments—in order to keep Medicare operating in the future.

Obviously, cutting provider payments has always been an unpopular tack, so year after year, going all the way back to 2003, Congress has delayed the mandated cuts with short-term policy moves. The delay is often referred to as the “doc fix.” Trouble is, the 17 successive doc fix policies did nothing to remedy Medicare’s impending insolvency.

Here comes MACRA

Stakeholders and policymakers alike wanted a permanent, more rational solution. In April 2015, the president signed the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), which supplanted the original rules and obviated the doc fix.

MACRA sets up the federal government to instead pay Medicare providers under a value-based model, in hopes of getting spending under control. Now providers have a Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models. The models are sweeping reforms and attempt to streamline some older reimbursement programs.

According to the National Council for Behavioral Health, the majority of behavioral health organizations that bill Medicare Part B will be subject to MIPS in 2017 with a few exceptions.

What’s the incentive?

Starting in 2019, MIPS-eligible clinicians will see payment adjustments between -4% and +4%. The range of payment adjustments will increase every year up to 9% by 2022. Extra bonuses up to 10% for exceptional quality are also up for grabs.

Who is eligible?

Physicians, psychiatrists, nurse practitioners, physician assistants, clinical nurse specialists and nurse anesthetists are eligible, but there’s a very long list of who is not eligible here including social workers and others in the behavioral health specialty. Remember the model is only for seasoned Medicare providers—those who are billing Medicare Part B more than $10,000 in claims per year.

Now what?

Even if you aren’t eligible for MACRA money, learn about the measures and incentives through the National Council or the Centers for Medicare and Medicaid Services (CMS). There are all kinds of tip sheets and webinars to be had.

You might as well get the education. Value-based models from all payer types are imminent, and federal programs have a way of bleeding over to the commercial market.

The CMS public comment period on the proposed rule ended in June, and the final rule is slated for publication by November 1. The first performance year begins January 1, 2017.


Julie Miller

Editor in Chief

Julie Miller


Julie Miller has more than 14 years of experience observing, analyzing and reporting on various...