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MACRA/MIPS/Advanced APMs

MACRA/MIPS/Advanced APMs

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) established two payment models within Medicare's Quality Payment Program. The first, the Merit-based Incentive Payment System (MIPS), is the model that applies to most psychologists.

MIPS combines three previous stand-alone Medicare programs: The Physician Quality Reporting System, the Value-Based Modifier and Meaningful Use. Participants in MIPS, known as MIPS eligible clinicians (MIPS ECs), submit data in four separate categories and receive a total composite score. The composite score for a given year is then used to determine the amount of incentive or penalty the MIPS EC's payments will receive two years later. For 2020, the amount of possible payment adjustment is 9%.

As MIPS ECs, psychologists are required to participate unless they fall under the low-volume threshold (LVT).

For 2020, a psychologist will fall under the LVT and be exempt from MIPS if they meet one of the following criteria:

  • Treat 200 or fewer Medicare Part-B beneficiaries.
  • Bill Medicare Part-B for $90,000 or less in allowed charges.
  • Provide 200 or fewer covered professional services.

Also for 2020, CMS created an “opt-in” option for those psychologists who fall under the LVT but still want to participate in MIPS to potentially receive reimbursement incentives. To opt in, a provider only has to meet one of the LVT criteria. To put it simply: Only one LVT criteria must be met to be exempt from MIPS reporting and only one must be met to choose to opt in.

The second payment structure is the Advanced Alternative Payment Models (APMs) which require the use of certified electronic health record technology, quality measures like those in MIPS, and the assumption of risk for financial expenditures that exceed expectations. ECs participating in APMs are excluded from MIPS and will receive a five percent incentive payment each year from 2019 through 2024. APMs are similar to medical homes and most are designed to provide primary care. While a psychologist could be part of an APM most psychologists provide services in traditional Medicare and would report under MIPS.

Last updated: October 2020Date created: June 2018