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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) makes sweeping reforms to payments under Medicare Part B, which could lower or increase the amount your agency is reimbursed by Medicare.

The Centers for Medicare and Medicaid Services’ (CMS) Quality Payment Program has two parts: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs). Both mechanisms focus on moving from payment for volume to payment for quality and value, and non-participation will result in reductions in reimbursement. The vast majority of behavioral health organizations that bill Medicare Part B are subject to MIPS.

On November 2, 2017, CMS released a Final Rule for Performance Year 2018 of the Quality Payment Program (QPP) under MACRA. CMS is continuing many of their 2017 transition policies, while implementing modest changes, including:

  • Raising the performance threshold to 15 points in Year 2 (from 3 points in the transition year)
  • Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2, and giving a bonus for using only 2015 CEHRT
  • Giving up to 5 bonus points on final scores for treatment of complex patients
  • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters
  • Adding 5 bonus points to the final scores of small practices

CMS also added more options for small practices (15 or fewer clinicians) including:

  • Excluding individual MIPS eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries
  • Adding 5 bonus points to the final scores of small practices
  • Giving solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices
  • Continuing to award small practices 3 points for measures in the Quality performance category that don’t meet data completeness requirements
  • Adding a new hardship exception for the Advancing Care Information performance category for small practices

What is MIPS?

MIPS collapses three existing quality reporting programs into one, while adding a fourth category:

  • The Physician Quality Reporting System (PQRS) becomes Quality under MIPS, and requires eligible clinicians to report certain quality measures on an annual basis.
  • The Value-based Payment ModifierProgram (VM) becomes Cost under MIPS. This category analyzes claims data to compare costs to treat similar care episodes and clinical condition groups across practices.
  • The Medicare Electronic Health Record (EHR) incentive program becomes Advancing Care Information under MIPS, and retains an emphasis on interoperability and information exchange.
  • A brand-new performance category is Improvement Activities, which rewards practices that engage in quality improvement activities, including for their Medicaid and other non-Medicare patient populations.

The first performance period (Performance Year 2017) closed December 31, 2017. The first payment adjustments based on performance go into effect on January 1, 2019.

CMS launched a data submission system that eligible clinicians can use to submit performance data as required under MACRA. Clinicians can submit their MIPS data through one platform on the Quality Payment Program website. CMS released a fact sheet, press release, and the following instructional videos:

Depending on the track of the Quality Payment Program you choose and the data you submit, your 2019 Medicare payments will be adjusted up, down, or not at all. The information provided below is only relevant for the 2019 payment year. CMS will provide additional information on payment adjustments for 2020 and beyond, this year.

The size of your payment adjustment will depend both on how much data you submit and your quality results.


Who is Eligible?

Clinicians that will be counted for the 2018 reporting year include physicians (including psychiatrists), nurse practitioners, physician assistants, clinical nurse specialists and nurse anesthetists. In 2018, MIPS does NOT apply to:

  • Clinical psychologists & licensed clinical social workers
  • First-year Medicare providers
  • Qualifying Advanced APM clinicians
  • Hospitals and facilities
  • Providers who fall beneath CMS’s low-volume threshold, who serve fewer than 100 Medicare recipients or bill Medicare less than $30,000 per year.
  • Clinicians and groups who are not paid under the Physician Fee Schedule (e.g. FQHCs and partial hospitalization programs)

How to Prepare

  • Start NOW. 2020 payment adjustments will be based on 2018 performance
  • Determine MIPS eligibility. Are you below the low-volume threshold of seeing fewer than 200 Medicare patients AND billing Medicare less than $90,000 per year? Is 2018 your first year billing Medicare? Is your organization an FQHC, hospital or facility? If the answer is yes, MIPS does NOT apply to you in 2018.
  • Educate your team. Make sure that your staff and leadership understand MIPS, how it will measure performance, and how it may affect Medicare reimbursements starting in 2019.
  • Explore National Council learning community opportunities and other technical resources that can improve your performance under MIPS.
  • Familiarize yourself with MIPS behavioral health-related quality measures. Which quality measures best suit your clinical practice? Check these measures against measures for other quality program initiatives to maximize efficiency and performance levels.
  • Familiarize yourself with MIPS improvement activities.Determine which improvement activities you are already doing, and what steps you might need to take to maximize your improvement activities score in 2018
  • Connect with the CMS-funded Transforming Clinical Practice Initiative (TCPI). TCPI supports 29 Practice Transformation Networks and Support and Alignment Networks across the country, which provide resources and technical support to help practices improve quality of care, reduce costs, and prepare for value-based payment arrangements. Visit or contact the National Council to learn more.
  • Connect with a Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs): The QIO Program’s 14 QIN-QIOs bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. More information about QIN-QIOs can be found here.
  • If you have an EHR, make sure it is certified EHR technology (CEHRT). A well-designed CEHRT can help you fulfill current quality reporting requirements and provide real-time summaries of your progress on quality measures. If you have an EHR, determine whether it is 2014- or 2015- edition certified—the version will determine your reporting measures in 2018.”
  • If you don’t have an EHR, use a clinical data registry.Clinical data registries can streamline reporting, help identify high-risk populations, and improve clinical practice.
  • Learn as much about the Quality Payment Program as you can—even if MIPS does not apply to you. Value-based payments are an important goal for all the major payers, not just Medicare. To meet these demands, all behavioral health organizations will need to cultivate an organizational culture that embraces change, and develop the infrastructure needed to measure progress, demonstrate value and improve health outcomes.
  • Stay Up-to-Date. The National Council will help you stay informed so you can meet your requirements every year. Subscribe to the National Council’s Capitol Connector blog.

2017 Submission Resources

Physicians had until March 16, 2017 for group reporting via the CMS web interface and March 31, 2017 for all other MIPS reporting via the  Quality Payment Program website.

Additional Resources for Performance Year 2 (2018)


Need more? Stay up-to-date with the National Council Capitol Connector Blog. For more information or questions, contact Dana Foney at



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