The medical world is full of acronyms that all make perfect sense to those in the business. The world of medical billing is constantly being introduced to a whole new set of important and changing phrases that affect a physician’s ability to participate in Medicare reimbursements.
Some of these terms have been in use for a couple of years and other are new. We break it all down below. We hope you find information that will help your office gain the best benefit possible regarding Medicare reimbursements.
MACRA (Medicare Access and CHIP Reauthorization Act)
Created in 2015 MACRA ended the Sustainable Growth Rate (SGR) formula. MACRA requires the implementation of an incentive program known as the QPP or Quality Payment Program. There are two ways clinicians can choose to participate in the Quality Payment Program; MIPS and Advance Alternative Payment Models.
What is MIPS?
The Merit-based Incentive Payment System (MIPS): If you’re a MIPS eligible clinician, you’ll be subject to a performance-based payment adjustment through MIPS. MIPS combines three legacy programs into one incentive-based payment program:
  • Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals
  • Physician Quality Reporting System
  • Value-base Payment Modifier
The MIPS Track of the QPP Requires:
  • Bill more than $90,000 per year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS).
  • Provide services to more than 200 Medicare beneficiaries per year.
  • Provide more than 200 covered professional services under the PFS.
If your clinic does not exceed the standards above in 2019, you are excluded from MIPS. There may be an opportunity to opt-in to MIPS if you meet or exceed some, but not all the low-volume threshold criteria.
Exclusions from MIPS
  • If this is your first year of enrollment in Medicare
  • You already participate in an Advanced APM and are a Qualified APM Participant (QP)
  • If you are in an Advanced APM and are determined a Partial QP and do not elect to participate in MIPS.
What is the Advanced Alternative Payment Model?
Advanced Alternative Payment Models (APMs): If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for sufficiently participating in an innovative payment model.
Under the Medicare Access and CHIP Reauthorization Act of 2015, to be an Advanced APM, an APM must meet all the following three criteria:
  1. Require participants to use certified electronic health record technology (CEHRT);
  2. Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of the Merit-based Incentive Payment System (MIPS);
  3. Either: (1) be a Medical Home Model expanded under CMS Innovation Center authority; or (2) require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses.
This link ( provides more in-depth information on MIPS, APM, and MACRA:
  • A 2019 MIPS Quick Start Guide
  • 2019 MIPS Participating and Eligibility Fact Sheet
  • Quality Payment Program Access User Guide
  • MIPS Scoring Guide
  • Comprehensive List of APMs (Alternative Payment Models)
If you need help with medical billing and getting the most from it, we can help. Contact us today for your consultation.
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