A stethoscope and American money on a white background - HealthcMACRA is making big changes to Medicare clinician reimbursement, so which clinicians are affected?

Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician except in certain circumstances. A MIPS Eligible Clinician (defined at 42 C.F.R. §414.1305) is a:

  • physician, including: (1) a doctor of medicine or osteopathy; (2) a doctor of dental surgery or of dental medicine; (3) a doctor of podiatric medicine; (4) a doctor of optometry; and (5) a chiropractor;
  • physician assistant, a nurse practitioner, and clinical nurse specialist;
  • certified registered nurse anesthetist; or
  • group that includes at least one of the clinicians above.

A MIPS Eligible Clinician is subject to the MIPS for a performance year unless the MIPS Eligible Clinician is excluded from participation under 42 C.F.R. §414.1310(b) & (c) because the MIPS Eligible Clinician:

  • is a qualifying advanced alternative payment model (APM) participant;
  • is a partial qualifying APM Participant that does not report on applicable measures and activities that are required to be reported under MIPS for any given performance period in a year;
  • does not exceed the low-volume threshold ($30,000 in Medicare Part B allowed charges or 100 Medicare Part B enrolled Medicare beneficiaries); or
  • becomes enrolled in Medicare for the first time during the performance year.

For the 2017 performance period, CMS estimates that, of the approximately 738,000 to 780,000 clinicians billing under the Medicare PFS, half will be excluded from MIPS.

Other clinicians that are not MIPS Eligible Clinicians, may voluntarily report measures and activities for MIPS, but will not be subject to MIPS payment adjustments. These unaffected clinicians are a:

  • certified nurse-midwife;
  • clinical social worker;
  • clinical psychologist;
  • registered dietician or nutrition professional;
  • physical or occupational therapist or qualified speech-language pathologist; and
  • qualified audiologist.

Links to other posts in this series

Managing MACRA – Part IV: When does it begin?

Managing MACRA – Part III: What is an APM?

Managing MACRA – Part I: What is MACRA?