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November 9, 2016

Physicians Face Medicare Payment Reform Under MACRA Final Rule Implementing the Quality Payment Program

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released an over 2,000 page final rule implementing the Quality Payment Program under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). MACRA repealed the Medicare Sustainable Growth Rate payment formula for physicians and replaced it with the Quality Payment Program. The Quality Payment Program aims at rewarding high-quality, cost-efficient patient care and establishes two payment systems to choose from: (1) Advanced Alternative Payment Models (APMs); or (2) the Merit-based Incentive Payment System (MIPS).

Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill Medicare more than $30,000 per year and care for more than 100 Medicare patients per year fall within the scope of the Quality Payment Program. Clinicians who take part in an Advanced APM may earn incentive payments through Medicare for participating in an innovative model; those who take part in traditional Medicare will participate in MIPS and can earn performance-based adjustments. MIPS focuses on quality, cost and use of certified EHR technology and replaces three Medicare reporting programs: the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record Incentive Program.

The first performance period will open January 1, 2017 and end December 31, 2017, but participants can choose to begin anytime between January 1 and October 2, 2017, with performance data due by March 31, 2018. Depending on data submitted by this date, Medicare payments will be adjusted up, down, or kept the same. Those who choose not to send any data in for 2017 will receive a negative 4% payment adjustment. The final rule was published in the Federal Register on November 4, 2016, and is available here. Additionally, a new CMS Quality Payment Program website is available here. If you have questions regarding how to comply with the new rule, please contact Susan Benz at 716-858-3812 or


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