What is MACRA 2021?

MACRA, short for the Medicare Access and CHIP Reauthorization Act of 2015, is a federal law that changed the payment system for doctors who treat Medicare and Medicaid patients. Under MACRA, physicians are reimbursed by Medicare and Medicaid based on quality of care and patient outcome measures. MACRA took the place of a system where provider reimbursement rates were tied to the growth (or decline) of the U.S. economy. Under MACRA, a system called the Quality Payment Program (QPP) is used to “score” physicians. One performance measure is the Merit-Based Incentive Payments System, or MIPS. MIPS scores physicians in four categories. Physicians who receive higher MIPS “grades,” by meeting MIPS criteria, are eligible for positive payment adjustments. This means that the Centers for Medicare and Medicaid Services may upwardly adjust reimbursement rates. Those clinicians who receive lower grades, by not meeting the criteria, are subject to negative payment adjustments. MACRA 2021 is discussed below.

What is MACRA 2021: The Components of MIPS

MACRA 2021

MIPS scores rate an eligible clinician’s overall yearly performance in four categories:

  1. Cost (based on overall Medicare claims)
  2. Quality (based on clinical specialties and practices)
  3. Improvement (based on efforts like improved coordination of care, safety, and beneficiary engagement)
  4. Promoting Interoperability. This performance category, formerly the Advancing Care Information category, directly involves compliance with the HIPAA Security Rule. 

Eligible clinicians’ performance in each category is assigned a score. The scores are then weighted (some categories make up a larger part of the total score than others) and totaled to yield a final score. The final MIPS score, which ranges from 0-100 points, will determine the payment adjustment an eligible clinician receives.

The data submission period for MIPS-eligible clinicians who participated in the 2020 performance year of the Quality Payment Program (QPP) ends on March 31, 2021.

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MIPS 2021 Eligibility

To be a MIPS-eligible physician for the year 2021, a physician must:

  • Be an eligible clinician type;
  • Be enrolled in Medicare before January 1, 2021; 
  • Not be identified as a qualifying APM participant (APM is one QPP program; MIPS is the other); and
  • Exceed a low-volume threshold. A clinician must exceed the low-volume threshold by providing care to Medicaid patients that is above a certain volume. Volume has three components: the amount of allowed charges billed to Medicare; the amount of Medicare patients a provider has provided services to; and the number of covered professional services furnished by the provider).

What To Do If You Are MIPS-Eligible for 2021

If you are MIPS-eligible for 2021, you must submit data for the quality, improvement activities, and promoting interoperability performance categories. CMS collects and calculates data for  the cost performance category.

Performance across the MIPS performance categories, each with a specific weight, will result in a MIPS Final Score from 0 to 100 points. 

The categories for performance year 2021 are weighted as follows:

  • Quality: 40%
  • Cost: 20%
  • Promoting Interoperability: 25%
  • Improvement Activities: 25%

The MIPS Final Score will determine whether you receive a negative, neutral, or positive MIPS payment adjustment. Your MIPS payment adjustment is based on your performance during the 2021 performance year and applied to payments for covered professional services beginning on January 1, 2023.

MACRA 2021: Promoting Interoperability

The promoting interoperability category requires completion of a HIPAA security risk analysis. Under MACRA, the purpose of the assessment is to secure protected health information (PHI).

The risk analysis consists of the following:

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