Want to avoid Medicare penalties under MACRA?

November 3, 2016

Sure you do. And we can help.

Unless you’ve been living under a rock (or avoiding revenue issues like the plague) chances are you’ve heard the Centers for Medicare and Medicaid Services released the Medicare CHIP and Reauthorization Act (MACRA) Final Rule upon the masses in mid-October. But what does that really mean in terms of how your practice’s Medicare Part B revenue stands to be impacted?

We’ve covered seemingly every aspect of MACRA and the Merit-based Incentive Payment System since its passage in 2015 and numerous iterations along the way. And we’ve broken down the system’s various components at length, including taking looks at the varying reporting obligations specialty clinicians face as opposed to their primary care counterparts. This paper, conversely, is intended to provide a brief overview of the action steps most pathologists can take to avoid a penalty to their 2019 Medicare reimbursements based on their MIPS performance next year.

MORE: Read our breakdown of the major changes put forth in the final rule.

Understand that this won’t answer all your questions if you’re just jumping into the game. But rest assured, we’ve done the research and have answers to nearly any scenario you can think of. Give us a call at 517-486-4262 or email amitchell@vachettepathology.com and we’ll be happy to look into your unique situation.

Is there a way I can avoid MIPS?

Do you or your group receive less than $30,000 in Medicare Part B payments and see fewer than 100 Medicare patients each year? Are you participating in an Advanced Alternative Payment Model (APM)? Are you a first time Medicare enrollee? Unless you answered “yes” to any of these questions, then you’re most likely stuck going along for the ride.

What qualifies an APM as “advanced”?

CMS has identified a handful of APMs that use certified EHR technology, feature payments tied to quality metrics similar to those measured by MIPS and require participants to bear some financial risk for reimbursement.

In order to avoid MIPS reporting, a clinicians must receive at least 25 percent of their Medicare Part B payments through an advanced APM or see at least 20 percent of their Medicare patients through the model. Those who meet this requirement during the 2017 performance year will automatically receive a 5 percent lump sum incentive payment in 2019. Eventually, participants under this track will also receive a higher annual fee schedule increase.

Below is a list of APMs that will qualify for the 2017 performance year:

  • Track 2 and Track 3 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs)
  • Pioneer ACOs
  • NextGen ACOs
  • Oncology Care Model two-sided risk arrangements
  • Comprehensive Primary Care Plus
  • Comprehensive ESRD Care

What if I participate in an APM that’s not on this list?

If you participate in an APM that’s not on the advanced list, or if you don’t receive enough Medicare payments through the model to meet the participant threshold (noted above), you will be required to report under MIPS, but will likely have a reduced reporting burden. Also, CMS expects to add more APMs to the advanced list each year, so there’s a good chance your model might receive the designation in future years. We’ll be happy to let you know what your requirements for 2017 are if you feel this situation applies to you.

OK, I can’t get out of MIPS. Now show me the path of least resistance.

If you dread performance reporting, you’ll be happy to know CMS has set an extremely low bar to successfully participate in MIPS during its initial year (which, remember, affects your 2019 Medicare payments because of the two-year gap between performance and payment.) Although MIPS has three categories that will be measured in 2017, most pathologists and many other specialists will not be scored in the Advancing Care Information category (an extension of the EHR Meaningful Use program) because most are considered by CMS to be “non-patient facing”, meaning that they have fewer than 100 direct patient encounters each year. If reporting as a group, at least 75 percent of the eligible clinicians in the group must fall below the 100 patient threshold for the group to be considered non-patient facing.

So that means most pathologists, including independent labs, will only be scored in the Quality category (PQRS) and the new Practice Improvement category.


To avoid a 2019 Medicare penalty, all you have to do is report one quality measurement or one practice improvement activity during 2017. That’s it. If you choose to do nothing, you’ll be automatically hit with a 4 percent Medicare penalty in 2019.

What are my options and how do I report?

Quality metrics can be reported via registry, claims or through a certified EHR. Groups of 25 or more also have the options to use the CMS web interface.

For pathologists, applicable quality categories include:

  • Breast Cancer Resection Pathology Reporting
  • Colorectal Cancer Resection Pathology Reporting
  • Barrett’s Esophagus Pathology Reporting
  • Radical Prostatectomy Pathology Reporting
  • Evaluation of HER2 for Breast Cancer Patients
  • Lung Cancer Reporting (biopsy/cytology specimens)
  • Lung Cancer Reporting (resection specimens)
  • Melanoma Reporting

Meanwhile, practice improvement activities can be reported by attesting you completed the activity, through a registry, through an EHR vendor, or via claims for individuals. Groups of 25 or more also have the option to use the CMS web interface. More than 90 practice improvement activities are listed by CMS, however, many initially appear not to apply to pathologists.

Here are three potential options identified by the College of American Pathologists:

  • Providing 24/7 access to the MIPS eligible clinician.
  • Participation in MOC Part IV.
  • Timely communication of test results.

To reiterate, you will completely avoid a penalty in 2019 if you just report one of the above items at any point during the 2017 performance year. YOUR MEDICARE REVENUE WILL BE PENALIZED IN 2019 IF YOU CHOOSE TO IGNORE MIPS.

If it’s that easy to avoid a penalty next year, why should I do more than I need to?

For starters, it’s definitely not always going to be this easy. While CMS has said 2018 will also be considered a “transitional” year, they’ve yet to explain what that will look like. And by 2019, everyone will be expected to be fully participating in MIPS, so it’s best to hit the ground running if you’re already confident in your quality reporting.

You also have the chance to open yourself up to the possibility of receiving a Medicare bonus of up to 4 percent in 2019 by either reporting for the full year or electing to report during an abbreviated 90-day window (albeit, for a smaller bonus). In 2017, CMS expects non-patient facing specialists who are seeking a bonus to report at least six quality measures for 50 percent of their Medicare patients if reporting via claims and to report on at least one high weighted or two medium weighted practice improvement activities.

And remember, you’ll already be exempt from a penalty just by reporting anything, so it’s best to test your reporting capabilities if you’re able. Think of next year as practice for the more difficult years to come.

Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

That’s right. For free.

Share This