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At the end of June, the Centers for Medicare and Medicaid Services (CMS) released the proposed final rule for year two of the Quality Payment Program, established under MACRA. Do you know how the proposed changes impact your urgent care practice?

What is MACRA?

MACRA is legislation passed in 2015; it stands for the Medicare Access and CHIP Reauthorization Act. It repeals the Medicare Sustainable Growth Rate (SGR) formula that paid clinicians based on volume of services rather than quality or value. MACRA replaces SGR with the Quality Payment Program (QPP), which is designed to reward the delivery of high quality patient care and consolidates various quality reporting programs.

What is the Quality Payment Program (QPP)?

The Quality Payment Program is tied to Medicare Part B and is facilitated by the Centers for Medicare and Medicaid Services (CMS). QPP was established under MACRA, and it has two Medicare Part B payment tracks:

  1. The Merit-based Incentive Payment System (MIPS)
  2. Advanced Alternative Payment Models (APMs)

The final rule for year two of the QPP is expected to be released November 1, 2017, and the timeline is quite aggressive:

  • October 2, 2017: Beginning of the last 90-day reporting period in 2017
  • November 1, 2017: Expected released date of the QPP year two final rule
  • January 1, 2018: Second performance year begins
  • March 31, 2018: 2017 performance year data is due


The MIPS track is the most relevant to urgent care practices. Payment adjustments are a percentage of a provider’s Medicare Part B billings and are performance-based, with scoring for the 2017 performance year conducted using four weighted categories:

  • Quality (previously QPRS) ” 60% of score
  • Advancing Care Information Act (ACI) ” 25% of score
  • Improvement Activities (CPIA) ” 15% of score
  • Cost ” 0% of score (cost will not be measured in the first performance year, but CMS will provide feedback to participants to help them in the second performance year)

Payment adjustments for 2017 participation will be made in 2019.

Who is Eligible for MIPS?

Eligible clinicians include any physician, nurse practitioner, physician assistant or clinical nurse specialist who participates in and bills Medicare Part B. You are not eligible if:

  • You are newly enrolled in Medicare


  • You have less than or equal to $30,000 in Medicare Plan B allowable charges for the year or see less than or equal to 100 Medicare patients for the year

If you’re not sure whether you’re eligible, you can enter your NPI into CMS’ MIPS Participation Status tool to check your eligibility. Eligible clinicians can participate individually under the NPI and TIN to which they reassign benefits or as a group with two or more NPIs who reassign to a single TIN.

What Are My Options for Year One Participation?

CMS created a “Pick Your Pace” approach for year one participation:

  • Take Penalty: If you do nothing, a negative payment adjustment of up to -4% will be applied to your 2019 Medicare Part B payments
  • Avoid Penalty: Submit the minimum data within one category for any 90-day period to get a neutral payment adjustment
  • Earn a Potential Bonus: Submit all required data for the Quality, ACI and CPIA performance measures for any 90-day period to get a positive payment adjustment.
  • Earn an Enhanced Bonus: Submit a full year of performance data for the Quality, ACI and CPIA performance measures to ensure a larger positive payment adjustment

The exact amount of the potential and enhanced bonuses will be determined by your score compared to other eligible clinicians’ scores.

What About Meaningful Use?

Although Meaningful Use wasn’t mentioned in the MIPS performance categories, it hasn’t gone away; it’s been integrated into the Advancing Care Information (ACI) performance category. At this point, eligible clinicians can use EHR technology certified for either the 2014 or 2015 editions to report the 2017 objectives and measures; however, you’ll report different measures depending on your EHR’s certification year.

What Do I Do Now?

This is an extremely high-level overview of the QPP, and there are more changes coming in November. If you’re not sure where to go from here, follow this checklist to get you started:

  • Check your eligibility on the CMS website
  • Review the performance categories in more detail on the QPP website
  • Determine your 2017 participation level
  • Based on your participation level, determine what measure(s) to submit
  • Determine which registry you’ll use to submit data

It’s vital you check your eligibility and form a plan for how your practice will participate in the QPP because this will help you avoid a negative payment adjustment. However, be flexible with your plan because changes to the QPP might come in November if CMS implements any of the feedback it receives during the commenting period. Staying informed and agile will help you navigate this new legislation.

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.

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