In recent years, providers and practice groups have been worrying about Meaningful Use (MU) and gaining knowledge on using certified electronic health record (EHR) technology to avoid payment penalties, earn incentives and increase practice efficiency. Now, with the release of the final rule for MACRA payment reform, physicians will have two options for payment paths: the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). On Jan. 1, 2017, the start of the reporting year, MACRA went into effect, replacing the Sustainable Growth Rate formula. This system will continue through Dec. 31, 2026. In 2018, physicians can potentially expect another transition year of reporting and, in 2019, benchmarks and reporting will start to substantially affect reimbursements.
MIPS consolidates different programs and regulations, such as the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier and MU, which was renamed to Advancing Care Information (ACI), along with the new requirements of showing clinical practice improvement activities in an effort to simplify reporting and to achieve goals that primarily include improving health outcomes for patients. Practices should be aware that PQRS does and will ultimately tie into MIPS. But the CMS will look at specific key clinical practice activities, and these activities will be the measures and/or key performance indicators that providers need to be cognizant of during the transition.
APMs are the alternative; although there are limited options to join an APM in 2017, this may change in coming years. Currently, the ACR is exploring a rheumatology-specific APM, which will be designed to give rheumatologists the resources and flexibility needed to deliver appropriate, cost-effective treatment for patients with rheumatoid arthritis. Providers can reach out to the ACR to help determine the best way to structure their care to meet the requirements, because following the APM path exempts a provider from the MIPS pathway.
MACRA Implications to Compliance
Compliance officers may feel like bystanders or observers, but MACRA is a catalyst that pushes the participation in compliance not as a process, but as a culture. This requires everyone to view compliance as an important component in the planning, preparation and implementation of operation strategies for efficiency. Because there are clinical practice improvement elements within MIPS that include expanding access to the practice and coordination of care, which includes phone and digital communications, practices will need to maintain security within their reporting functions to avoid HIPAA violations.
Additionally, the compliance department will need to stay abreast of regulations and understand the implications of MACRA on the elements of education, auditing and monitoring for coding and billing; clinical documentation; EHR use; and physician contracts.
How Can Practices Prepare?
No one should bury their head in the sand. It is vital to have continuous dialogue with staff and post information and key dates for different areas of MIPS reporting requirements and implementation. Be sure to stay up to date with CMS and your EHR vendor for any changes or necessary updates for providers to meet their goals in performing measures. Other important points to understand and keep in mind:
- Providers may be able to opt out of attesting data in 2017, but will receive negative adjustments in 2019. Special assistance and accommodations will be made available to providers in rural settings and larger practice groups.
- Providers can choose between a 90-day and a full-year reporting period. Note that most reporting choices weight bonuses and penalties. MIPS will encourage quick adoption, with few loopholes or delays.
- PQRS data will be published and used as benchmarks for 2017. Reporting data for each year can be found on the CMS website.
- Providers will not be evaluated on cost or resource use during the first year. Providers are encouraged to track this data to help to determine the progress, baseline and areas of improvement.
- Work closely with your EHR vendor to ensure you understand how to use the EHR effectively and efficiently. Even if your EHR is not ready to start calculating for MACRA now, using your EHR correctly is vital to ensure calculations are useable later.
- Sign up for the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry.
Additional Precautions
Practice administrators and compliance officers should make sure that providers and staff are not sharing login credentials for patient charts, because this is a HIPAA violation. More importantly, it will cause inaccurate credits and penalties to be applied to patient charts and provider calculations. Individual staff at the practice should each have their own login. Also:
- Verify starting/signing charts: If your EHR allows charts to be started by one provider and signed off on by another, it is important to understand how that EHR is applying credit and that the appropriate providers are participating as their scope allows.
- Stay up to date: Due to volume and other duties, practices may fall behind and constantly play catch-up, making it difficult to record all of the necessary information to file claims in a timely manner and increase earning potential. Entering backdated information runs the risk of the EHR not calculating information correctly, or it being entered inaccurately, which may have a negative effect in the long run.
Physicians and their staff will need to maximize the effectiveness of compliance and ethics policies in the practice. The new payment structure under MACRA will change the dynamic of many compliance measures and practice procedures, but promises to simplify the healthcare platform to create a value-based healthcare model. This regulation and the requirements are a moving target; it is imperative practices monitor for updates on the guidelines as they are published by CMS and the ACR.
