5 Things NPs Need to Know About MACRA

The alphabet soup that is provider reimbursement got a bit thicker over the past few weeks. MACRA, MIPS, and APM are among the new acronyms healthcare providers must know to get paid. The Centers for Medicare and Medicaid Services (CMS) finalized the Medicare Access and CHIP Reauthorization Act (MARCA) last month. Effectively, this ruling changes the standards by which Medicare reimburses healthcare providers. What do nurse practitioners need to know about the act?

MACRA reforms the way providers are reimbursed

As I discussed in my previous blog post on the topic, MACRA is the latest step in the process to move provider reimbursement from a fee-for-service model to a model that compensates providers based on quality of care and other performance measures. Traditionally, physicians, nurse practitioners, and physician assistants have been compensated based on the number and complexity of services rendered to patients, rather than the quality of such services. A calculation, known as the sustainable growth rate formula (SGR) determined the rate of reimbursement for such services, often cutting payment to providers year-over-year. MACRA eliminates the SGR formula, implementing a new structure for determining reimbursement which rewards higher quality care. 

There are two new payment pathways

There are two tracks by which healthcare providers may be paid under the new reimbursement structure: 

  • Merit-based Incentive Payment System (MIPS)
  • Alternate Payment Models (APMs)

The MIPS pathway includes Medicare's existing quality reporting measures, consolidating them into a single program. Providers will be scored in four areas including clinical quality, resource utilization, advance care information (formerly known as 'meaningful use'), and clinical practice improvement activity. The numbers will be aggregated into a single final score to determine if the provider will be penalized or rewarded based on performance. The majority of providers will be subject to the MIPS model. 

The second track, the APMs pathway, modifies the reimbursement program for a few, specific types of organizations.

New policy may financially reward or penalize providers

On the MIPS reimbursement track, providers scoring below a certain threshold may have payments negatively adjusted, with a maximum penalty of 4% in 2019, increasing to a maximum penalty of 9% in 2022. Providers scoring above a certain threshold on performance measures may see payment positively adjusted on the same sliding scale. 

Nurse practitioners are specifically included

Historically, nurse practitioners have not specifically received mention in most Medicare rulings. Rather, CMS policy typically applies to NPs by way of their relationship with physicians. MACRA, however, specifically applies to non-physician providers such as nurse practitioners, physician assistants, clinical nurse specialists, and CRNAs. 

You'll need to get started immediately

While clinicians won't see new CMS reimbursement policy affect their pocketbooks until 2019, the new Merit-Based Incentive Payment System (MIPS) kicks off in 2017. Performance data collected in 2017 will determine 2019 reimbursement rates. Given the immediacy of this timeline, practices won't be required to report data for the full calendar year. Rather, clinicians will only need to report data for any continuous 90-day period in 2017. Reporting more than the minimum amount of data, however, increases the chances of more favorable reimbursement.

With "one of the most significant stand-alone Medicare payment reform pieces of legislation in decades" rolling out in 2017, nurse practitioners can expect changes coming their way. How will MACRA affect your practice?


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Hi Gail, 

Good question. Not holding a national certification can be a problem when it comes to reimbursement. I would highly advise becoming certified even if it is not required by your state. I will look into it as it relates to new CMS policy...

Erin Tolbert

What happens to the NPs who do not have a national certification.