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2 Disclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws. This should not be used as legal advice. Itentive recognizes that there is not a one size fits all solution for the ideas expressed in this webinar; we invite you to follow up directly with us for more personalized information as it pertains to your specific practice and issues. Thank you, and enjoy the webinar.

3 About Us Our passion is to provide solutions for our healthcare provider partners which help them improve patient care, enhance the patient experience and maintain a financially healthy practice. Since 2003 we have specialized in NextGen Healthcare services including: Consulting Hosting Customization And productivity tools such as ChartGuard and RefundManager

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5 Breaking Down MACRA

6 Introductions Cindi Kincade Vice President, Consulting Solutions Lindsey Lanning Healthcare Compliance Consultant Kathy Griseta Relationship Manager

7 Breaking Down MACRA

8 Today s Agenda Overview of MACRA and the Quality Payment Program MIPS Quality Resource Use Clinical Practice Improvement Activities Advancing Care Information MIPS Scoring and Payment Adjustments APMs How You Can Prepare

9 OPPS and ASC Final Rule For eligible hospitals, CAHs and dual-eligible hospitals attesting to CMS, eliminating the Clinical Decision Support (CDS) and Computerized Order Entry (CPOE) objectives and measures beginning in 2017, reducing a subset of thresholds for the remaining objectives and measures for Modified Stage 2 in 2017 and Stage 3 in 2017 and 2018, and adding new naming conventions to measures for Modified Stage 2 and Stage 3. Allowing all returning participants in the EHR Incentive Programs to report on a 90-day EHR reporting period in 2016 and A hardship exception to the Medicare EHR Incentive Program for EPs in 2017 who are new to the MU program and plan on transitioning to MIPS in 2017.

10 Take a deep breath and relax

11 MACRA Overview

12 MACRA Overview On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide. This was finalized on October 14, 2016.

13 MACRA Reform Pre - MACRA Annual doc fixes to avert cuts due to SGR Fee-for Service system Three separate quality reporting programs Post MACRA Permanent repeal of SGR Value-based payment Streamlines all 3 quality programs into one (The Quality Payment Program)

14 MACRA Final Rule Key Changes Transition year for 2017 Pick your pace option Resource Use/Cost category zeroed out Low-volume threshold adjusted Reduced measures for ACI and CPIA and lower reporting thresholds for ACI category Expanded APM participation Increased support for small practices

15 MACRA-nyms Acronym Stands for Actually means ACI APM CPIA MIPS Advancing Care Information Alternative payment model Clinical Practice Improvement Activities Merit-Based Incentive Payment System New Meaningful Use Risk-based payment arrangements New performance category under MIPS The new MU, VBM, and PQRS program EC MIPS-eligible clinician Physician, NP, PA, CNS, or CRNA QPP Quality payment program MACRA rebranded QP Qualified Participants Providers participating in an APM

16 Quality Payment Program Overview The Quality Payment Program is a unified framework that includes two paths: Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs) Combines Meaningful Use, Physician Quality Reporting System, and Valuebased Modifier into the new Merit-based Incentive Payment System (MIPS)

17 What Now?

18 MIPS vs. APM Participation The majority of practitioners will be subject to MIPS in 2017 versus APMs

19 Merit-Based Incentive Payment System

20 What is MIPS? The MIPS program combines existing quality reporting programs PQRS, the Value-Based Payment Modifier, and Meaningful Use and rolls them into a single program. The single program contains four performance categories: quality, advancing care information (ACI), improvement activities, and cost. A clinician s or group practice s performance in these four categories will determine their performance score and their payment rate.

21 Who is Included? Eligible Professionals are now called MIPS Eligible Clinicians MIPS Eligible Clinicians are the Medicare Part B eligible clinicians affected by MIPS

22 Who is Not Included? Providers billing Medicare for the first year Clinicians, groups that fall under the low-volume threshold Less than or equal to $30,000 a year in Medicare part B charges or provide care for less than 100 Medicare patients Groups with significant participation in APMs Medicare Part A (e.g., hospital payments) Also Note: MIPS does not apply to Medicaid. If you are a clinician who bills under both Medicare Part B and Medicaid and are ABOVE the low patient volume threshold then you will have to dual report or you will see penalties from Medicare.

23 MIPS Performance Categories Quality Cost Advancing Care Information Improvement Activities MIPS Composite Score

24 Category Weights Image source: mgma.com/macra

25 MIPS Category: Quality Replaces the Physician Quality Reporting System (PQRS) Report 6 quality measures including 1 outcomes measure (or high-priority measure if none available); or select a specialty measure set for a minimum of 90 days Choose from 300+ individual measures or 30 specialty measure sets Quality measures will be selected annually through a call for quality measures process, and a final list of quality measures will be published by November 1 of each year Different requirements for groups reporting CMS Web Interface or those in MIPS APMs

26 Measure Examples

27 MIPS Category: CPIA New performance category ECs select and complete improvement activities (IAs) from inventory of high- and medium-weighted activities Attest yes/no to completing up to 4 IAs for 90 days for full credit Preferential scoring for certain ECs and groups Non-patient facing ECs and groups, small practices (<15 ECs), and practices in rural/hpsas automatically receive half credit Accredited medical homes automatically receive full credit MIPS APMs automatically receive full credit; other APMs receive at least half Opportunity to earn bonus points in ACI for use of CEHRT when performing certain IAs

28 Activity Examples

29 MIPS Category: Cost Replaces Value-Based Modifier Starts in 2018; weighted to 0 in first year CMS will still provide feedback based on 2017 claims data All measures are calculated by CMS based on administrative claims collected for a full calendar year; no reporting required Cost measures: Total per capita cost (for part A and B) for all attributed beneficiaries Medicare spending per beneficiary (MSPB) Additional episode-based measures

30 MIPS Categories: ACI Replaces the Medicare EHR Incentive Program, also known as Meaningful Use Fulfill the required measures for a minimum of 90 days: Security Risk Analysis e-prescribing Provide Patient Access Health Information Exchange Choose to submit up to 7 measures for a minimum of 90 days for additional credit. For bonus credit, you can: Report Public Health and Clinical Data Registry Reporting measures Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

31 ACI Measures In 2017, there are two measure set options for reporting. The option you use to submit your data is based on your electronic health record edition. Option 1: Advancing Care Information Objectives and Measures (15 measures) Option 2: 2017 Advancing Care Information Transition Objectives and Measures (11 measures)

32 ACI Score Base Score 50 Points Performance Score 90 Points Bonus Points 15 Points Total ACI Points 100 Points

33 2017 ACI Base Score The base score are required measures Failure by an EC to meet any of the base score requirements will result in a 0 for the Base Score and a 0 for the entire ACI category Base score thresholds are either one patient or a yes/no attestation 2017 base score comprised of 4 required objectives (down from 11 in the proposed rule)

34 2017 ACI Performance Score The performance score are the measures you have the flexibility to choose to report on for additional points 7 performance measures are in the 2017 version (2 from base) Each measure is worth 10 points besides the 2 from the base score which are worth 20 points (patient access / HIE) 90 total points possible for performance score Total possible 155 points; only 100 required for maximum

35 Bonus Points ECs can earn up to 5% for reporting to one or more additional public health or CDRs beyond Immunization registry reporting (active engagement) ECs can earn up to 10% in the performance score for reporting a designated improvement activity using CEHRT

36 MIPS Performance Categories Quality Cost Advancing Care Information Improvement Activities MIPS Composite Score

37 Submitting MIPS Data

38 MIPS Data Submission- All Categories

39 2017 Measures Reporting Image source: mgma.com/macra

40 2017 Pick Your Pace This program is set to begin on January 1, 2017, however, CMS has established special policies for the first year of the Quality Payment Program, which they refer to as the transition year. During this year physicians are allowed to pick their pace of participation for the first performance period that begins January 1, 2017.

41 MIPS Composite Score Overview ECs Submit Data Category Scoring CPS Calculation Compare CPS with Performance Threshold Payment Adj. Determination Payment Adj. Applied 2017 MIPs Performance Threshold: 3 points (avoid a penalty) 2017 Exceptional Performance Threshold: 70 points (automatically earn a bonus ranging from 0.5% to 10%)

42 Timeline

43 MIPS Timeline Image source: mgma.com/macra

44 Projected MIPS Adjustments for 2017 Image source: mgma.com/macra

45 Avoiding a Negative Adjustment in 2019 Practices may report one of the following options to avoid a MIPS penalty: 1. One quality measure, or 2. One improvement activity, or 3. The ACI base measures We strongly encourage providers to report more than the minimum

46 Earning a Positive Adjustment in 2019 To maximize the MIPS score and potentially earn a bonus, practices should take the following actions: Quality ACI Report performance data spanning at least 90 consecutive days on up to six quality measures. Groups may earn up to 10 points per measure All measures will at least receive a score of 3 Report or attest to meeting 4 base measures for 12.5 points Report performance on 7 additional measures and earn up to an additional 12.5 points Improvement activities Attest to completing up to four improvement activities for at least 90 consecutive days for 15 points towards the 2017 MIPS score

47 Alternative Payment Models

48 Alternative Payment Models An Alternative Payment Model (APM) is a payment approach that provides added incentives to clinicians to provide high-quality and cost- efficient care Advanced APMs are a subset of APMs that enable clinicians to earn greater rewards for taking on some risk related to their patients outcomes APMs Advanced APMs

49 Advanced APM Eligible entities that participate in APMs must: Require the use of certified EHR technology, Provide for payment for covered professional services based on quality measures comparable to measures under the MIPS performance category, and Bear more than nominal financial risk for monetary losses OR be a medical home model expanded by the CMMI (Center for Medicare and Medicaid Innovation).

50 Advanced APM Models The application cycles for participation in these models have closed, but CMS intends to expand the list of Advanced APMs in 2018 and will also re-open the application cycles for CPC+ and the Next Generation ACO model for 2018 participation.

51 Incentives for APMs The QPP does not change the design of any APM instead it creates extra incentives for a sufficient degree of participation in advanced APMs - CMS Advanced APMs qualify certain participants for: Exclusion from MIPS reporting A 5% bonus payment Higher fee schedule updates beginning in 2026

52 Qualifying APM Participants Only qualified APM participants (QPs) in Advanced APMs will be excluded from MIPS in 2017 and receive a 5% lump sum bonus in 2019 To become a QP you must have a certain percentage of patients or payments through an Advanced APM Clinicians must have at least 25% of their Medicare Part B payments or 20% of their Medicare patient population flow through the Advanced APM Advanced APM participants who fall below the QP thresholds may be designated as Partial QPs. Partial QPs have at least 20% of their Medicare Part B payments or 10% of their Medicare patient population flow through the Advanced APM. Partial QPs will have the option to forego participation in MIPS, but will not be eligible for the 5% lump sum bonus payment

53 QP Determination The QP Performance Period is the period during which CMS will assess eligible clinicians participation in Advanced APMs to determine if they will be QPs for the payment year CMS will make QP designations three times during 2017 March 31, June 30, and August 31 Reaching the QP threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity Eligible clinicians will be notified of their QP status after each QP determination is complete (point D)

54 Not a QP or Partial QP? Those in non-advanced APMs or those who were determined not to be a QP or partial QP will participate in APMs and MIPS simultaneously In 2017, these clinicians and groups will receive full credit in the improvement activities category of MIPS automatically. If applicable, they will report quality measures through the APM and be evaluated on ACI performance collectively, as well

55 Preparing for Success

56 Preparation Questions: Quality Did you successfully report PQRS? How are you reporting? What measures are you reporting on? Do they match any offered under the MIPS Quality category?

57 Preparation Questions: Resource Use How did you do on VM? Do you know what VM is? Are you seeing a payment adjustment? Do you know if you are seeing a payment adjustment? Do you know how to review your QRURs? Enterprise Identity and Management System (EIDM) account required to access QRURs at

58 Preparation Questions: ACI Did you successfully report Meaningful Use in 2015 or previous years? Did you take advantage of the hardship in 2015 rather than attest? Have you recently ran your HQM reports? After running HQM reports would you pass MIPS ACI category today?

59 Preparation Questions: CPIA Have you looked at the activities available to report on? Are you currently participating in any activities listed right now? Are you a PCMH? Are you considered a small practice under MACRA?

60 Misc. Important Points Medicaid EHR Incentive Program remains separate Submission methods remain the same 90 day reporting in 2017 and 2018 ( to support CEHRT upgrade) Starting January 1, 2017 EC s will have 3 additional statements they must attest to: EC did not limit or restrict the compatibility or interoperability of certified EHR technology EC implemented technologies, standards, policies, practices, and agreements to allow for timely, secure, and trusted bi-directional exchange of electronic health information with other providers EC responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information Hardship exceptions are the same as existing 2016 Meaningful Use program If granted, ACI weighted to zero % for MIPS final score

61 By failing to prepare, you are preparing to fail. - Benjamin Franklin

62 Uncertain Where Your Practice Stands? Let Itentive help: By assessing your current readiness Providing recommendations Implementation of new processes and procedures

63 Next Steps Visit us Itentive.com Sign-up for our informative webinars and blog Consider our 3-day, fixed price on-site consultations: Clinical Workflow Revenue Cycle and Front Office Technology and Performance Test Drive our Products

64 Questions Lindsey Lanning Healthcare Compliance Consultant Kathy Griseta Relationship Manager Cindi Kincade Vice President, Client Solutions

65 Thank you

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