Indiana Providers Participating in an Accountable Care Organization Still Likely to be Subject to MIPS

Tuesday, May 31, 2016

Great Lakes Practice Transformation Network LogoThe final proposed rule for the Medicare Access and CHIP Reauthorization Act (MACRA) includes consolidation of 3 quality reporting programs currently being implemented by CMS. As proposed, MACRA would combine the Medicare EHR Incentive (Meaningful Use), the Physician Quality Reporting System (PQRS), and the Value Based Payment Modifier programs into one program called The Quality Payment Program. The Quality Payment Program is proposed to have 2 paths: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model.

Most providers will be eligible to participate in the MIPS path. Providers included in the list below are MIPS eligible for the first 2 years of the program if they have Medicare Part B claims during the reporting year. This list is expected to expand to allied health professional in the 3rd year of the program. The reporting year for the first year of MIPS is 2017. Payment adjustments will follow in 2019.

  • Physicians
  • Physician Assistants
  • Dentists
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Certified Nurse Anesthetists¬†

Some providers are excluded from participating in MIPS:

  • Providers that are in their first year of Medicare participation will not be subject to MIPS
  • Providers that have less than $10,000 in Medicare Part B claims and see less than 100 Medicare Part B patients during the reporting year will not be affected by MIPS payment adjustments
  • Providers that are participating in an Advanced Alternative Payment Model will not be considered eligible providers

Advanced Alternative Payment Models are defined by the features in the table below. Many of the Accountable Care Organizations (ACO) in the state of Indiana have many of these features, however, it is important to note that currently no ACO in the state of Indiana is participating in a qualified Advanced Alternative Payment Model. This is primarily due to the requirement that the participants must bear more than nominal risk for financial loss or participate in the in a Medical Home Model expanded under the Center for Medicare and Medicaid Innovation (CMMI) authority. As of today, the ACOs in the state of Indiana each participate in a model that allows them to accept nominal financial risk therefore they will be subject to MIPS. 

  • Use certified electronic health record technology (CEHRT)
  • Base payment on quality measures comparable to those in the MIPS quality performance category
  • Either:
    • Bear more than nominal financial risk for monetary losses
    • OR
    • Is a Medical Home Model expanded under CMMI authority



Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA -

Quality Payment Program -

Tags: Quality Services

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