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)opens in new window, submit data in four separate categories and receive a total composite score.

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

For 2024, a psychologist will fall under the LVT and be exempt from MIPS if they meet one of these 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

In 2020, the Centers for Medicare and Medicaid Services (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 must 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.

For required MIPS reporters or those who choose to opt-in, the four categories require data submission include:

• Quality – (includes patient reported outcome measures)
• Promoting Interoperability (PI) – (use of an EHR)
• Improvement Activities (IA) – (involve changes to practice that enhance accessibility and patient centered care)
• Cost – (calculated by CMS based on claims score)

These categories combine to give you a composite MIPS 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. In 2024, the overall performance threshold for the MIPS score will remain at 75 points. For more information on MIPS and how to successfully participate, please see the available webinar recordingsopens in new window from APA’s technology partner, Healthmonix.

CMS has begun transitioning from traditional MIPS to voluntary MIPS Value Pathwaysopens in new window (MVPs) and subgroup reporting in 2023. MVPs are the newest MIPS reporting option (an alternative to traditional MIPS and Advanced Alternative Payment Models [APMs] Performance Pathway) that you can use to meet your MIPS reporting requirements. MVPs offer more connected assessment of quality of care, enhanced performance feedback, and the reduction in reporting burden across CMS programs. There are multiple options for reporting MVPsopens in new window. The MVPs framework goal is to align and connect measures for different specialties or conditions across MIPS performance categories. MVPs focus on the quality, cost, and improvement of health care services, while incorporating the patient and provider voice. MVP participants include individual clinicians, single specialty groups, multispecialty groups, subgroups, and APM entities.

The second payment structure created by MACRA in 2015 is the Advanced Alternative Payment Models (APMs)opens in new window. APMs 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 5% 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.