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Making Sense of MACRA


Develop a Plan to Address Updates for 2018 Reporting

The Medicare Access and Chip Reauthorization Act (MACRA) was signed into law in 2016. Less than a year later, clinicians were expected to begin reporting. During the transition year (2017), the Centers for Medicare and Medicaid Services (CMS) allowed eligible clinicians to "pick their pace" for reporting into the quality payment program (QPP). Now, for 2018, clinicians must provide a full year of reporting on these measures. To add another layer of complexity, CMS has released new changes and updates for this year. An action plan put in place sooner, rather than later, can help ensure proper reporting.

Changes for 2018

Small Practice Relief

For small practices (groups of 15 or fewer clinicians), changes for 2018 could bring about some relief from the previous reporting requirements.

  • The virtual group option is now available, giving solo practitioners and small practices the choice to form or join a group to participate in the Merit-based Incentive Payment System (MIPS) with others.
  • The low-volume threshold has been extended to exclude individual MIPS-eligible clinicians or groups with less than or equal to:
    • $90,000 in Medicare Part B allowed charges, or
    • 200 Medicare Part B beneficiaries.
  • Five bonus points will automatically be added to the final score of small practices.

Practice Management Tip: Whether your practice has decided to report as a group or as individual clinicians, be sure to check all clinician eligibility through the MIPS Participation Status ( site to confirm if the clinicians in your practice are required to submit data to MIPS each year.

Performance Category Updates

As CMS moves towards full implementation of the QPP, many of the transition-year policies have been extended to allow for gradual implementation and further prepare clinicians for full implementation in 2019.

  • The cost performance category is being introduced and will hold a weight of 10 percent of the MIPS final score. For the current reporting year, no action is required by clinicians -- CMS will calculate cost measure performance. Look for further guidance on reporting in 2019 to be released towards the end of this year.
  • With the introduction of the cost performance category, the MIPS score is now comprised of the following:
    • Quality - 50 percent
    • Cost - 10 percent
    • Improvement activities - 15 percent
    • Advancing Care Information (ACI) - 25 percent
  • The ACI category carries the same weight of composite score as it did in the 2017 transition year, and the requirements to achieve the base score in the ACI category remain the same. However, there are additional ways to earn bonus points in this area during the 2018 performance year.
    • Practices can earn a 10 percent bonus to their ACI score by exclusively using 2015 Certified Electronic Health Record Technology (CEHRT).
    • Reporting to any single public health agency or clinical data registry can result in a 10 percent boost in the performance score, up from the 5 percent available in 2017.

Practice Management Tip: There is no specific information available to the public related to CEHRT requirements for the 2019 performance year and beyond. However, one could surmise that it may become required in the future. Thus, it is recommended that practice administrators and clinicians proactively consult with their technology teams to map out a course for 2015 CEHRT integration. These types of transitions can be more difficult to schedule (and end up being costlier) when performed after a requirement is announced.

Hardships & Exemptions

For the 2017 transition year, CMS allowed for the exemptions of extreme and uncontrollable circumstances, including natural disasters and public health emergencies. Unfortunately, numerous clinicians were affected in 2017. As a result, CMS has extended the application for both the transition year and the 2018 reporting year.

  • In 2018, clinicians in FEMA-registered disaster areas may submit a hardship application for the re-weighting of all three performance categories (quality, cost, and improvement activities).
  • MIPS-eligible clinicians may also submit a hardship exemption to be considered for re-weighting of the ACI performance category. Eligibility for this exemption includes:
    • Insufficient internet connectivity
    • Lack of control over the availability of CEHRT

Practice Management Tip: Clinicians who qualify can apply for a hardship exemption by visiting Applications may still be submitted for reporting year 2017 through March 31, 2018. Applications for 2018 will be available once the 2017 submission period has closed.


Clinicians who may not meet the requirements for reporting ePrescribing and Health Information Exchange (HIE) measures can still qualify for the 2017 exclusion established by CMS.

  • The ePrescribing measure requires reporting when at least one permissible prescription written by a MIPS-eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT.
    • If an eligible clinician writes fewer than 100 permissible prescriptions during the performance year, they are excluded from the ePrescribing measure. However, if the clinician is participating in MIPS as part of a group, the group must qualify the same way to be eligible for this exclusion.
  • For the HIE measure, a MIPS-eligible clinician who transitions or refers a patient to another health provider or setting of care must (1) use CEHRT to create a summary of care record and (2) electronically submit the summary to the receiving provider.
    • If an eligible clinician transfers patients to another setting or refers patients to other providers fewer than 100 times during the performance period, they are excluded from the HIE measure. However, if the clinician is participating in MIPS as part of a group, the group must qualify the same way to be eligible for this exclusion.

Action Plan 2018

For many eligible clinicians, 2018 will be the first year of full reporting. To ensure the highest incentive potentials, it's essential for practices to develop an action plan to meet CMS requirements. Some proactive steps to consider for 2018:

  • Determine the level of MIPS eligibility and ensure clinicians do not fall under the low-volume threshold.
  • Review performance categories.
    • Narrow down the quality measures that clinicians are frequently reporting. (Clinicians must report on six measures.)
    • Review current improvement activities. (More than 100 activities in nine subcategories are available.)
  • Review data from transition-year reporting. If not available, review meaningful use and PQRS reporting data from years prior to 2017.
  • Decide whether to report as an individual, group, or virtual group.
  • Identify a reporting mechanism.
    • Qualified Clinical Data Registry/Qualified Registry
    • CEHRT - Certified Electronic Health Record Technology
      2014 or 2015 editions are allowed, but bonus points will only be given for use of the 2015 edition.
    • Claims (available only to individual clinicians)
    • CMS Web Interface (available only for groups of 25 or more)

As clinicians are working on reporting for 2018, it is imperative that practices and facilities continue to educate personnel on the changes handed down from CMS, as additional alterations are expected in the months and years to come.

Feedback & Comments

Even though the compliance process can feel cumbersome, CMS is considering feedback and comments from clinicians, advisors, and vendors relating to the practicality of reporting requirements under these new rules. The changes relating to small practice relief, performance category adjustments, and hardship exclusions are just a few examples of how feedback is impacting the QPP.

There's no time better than now to have an internal conversation about your reporting requirements to ensure you have a plan in place for 2018. Make sure you have an educated team and the appropriate tools and procedures in place to achieve the maximum possible score for your clinicians and practice.

Jessica Benson, CPA, a supervisor on the KraftCPAs healthcare industry team, has more than nine years of experience in public accounting. Danielle Tribout, CPC, CPMA, CEMC, a coding and compliance consultant with Kraft Healthcare Consulting, has more than 12 years of experience in the healthcare industry. For more information, go online to



Kraft Healthcare

Quality Payment Program

MIPS Participation Status


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CEHRT, Danielle Tribout, ePrescribing, Jessica Benson, Kraft Healthcare Consulting, KraftCPAs, MACRA, Medicare Access and Chip Reauthorization Act, Merit-based Incentive Payment System, MIPS, Physician Reimbursement, QPP, Quality Payment Program
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