The payment adjustments under the Quality Payment Program’s (QPP) and Medicare Access and CHIP Reauthorization Act (MACRA) began in January 2024.

The QPP & MACRA went into full effect on January 1^st, 2022. But up until 2024, it was just a compliance checkbox issue and a nuisance. But now eligible TINs, physicians, and clinicians are receiving a positive or negative payment adjustment of up to 9% more, or up to 9% less on their Medicare Part B claims submissions, based on their TIN or ACOs Corresponding Performance Year final MIPS Score. (note* Critical Access Facilities & Federally Qualified Healthcare Clinics are exempt).

CMS calculates your MIPS score based on the following Category Weights Scores:

• Certified Quality Measures (CQM) – 30% of total score
• Promoting Interoperability (PI) – 25% of total score
• Improvement Activities (IA) – 15% of total score
• Cost – 30% of total score

MACRA requirements make up of thousands of pages of regulations in the Federal Registry and are a very complicated beast and no small task to manage or optimize. And now the NQS is adding even more complexity.

Though most TINs did a good job meeting Quality Measures in the past, due to apathy, complexity, and the failure of vendors to provide TINs and their providers with the proper tools, many are being penalized or missing the opportunity to qualify for the maximum payment adjustment of 9%.

Administrators even boast about their Quality Scores and robust QA audit teams and provider education. However, they are still apathetic about verification and actions needed because up until now the requirements have not amounted to any significant increase in revenue. This has now changed.

So, now when ownership, boards, and/or stakeholders ask why your TIN received a negative adjustment or failed to maximize the payment adjustment under the QPP & MACRA, and no one can explain why or do anything about it, ignorance or apathy will not be an accepted excuse. Don’t let this happen to you!

Our MACRA Optimization platform is vital and proactive solution for all Merit-Based Incentive Payment System (MIPS) eligible TINs, physicians, and clinicians.

To learn more about improving your PI score, see our HIE Optimization webpage.

The high cost of doing business has been met with inadequate increases in reimbursement by CMS. But MACRA can help.

The Corresponding Performance Year (CPY) is the 12-month period during which Quality, Promoting Interoperability, Improvement Activity, and Cost data is gathered, and after the close of the year, submitted to CMS. Around 6-months later, CMS calculates the payment adjustment (based on each TIN and physician’s MIPS score the population of the revenue neutral pool, which is capitalized from the physicians who are penalized).

The Payment Adjustment Year (PAY) is the 12-month period during which the CPY’s financial adjustment is applied.

Make sure you don’t leave any money on the table. Qualify for up to the maximum payment adjustment in the next PAY.

The only thing worse than failing to maximize your payment adjustment is not taking the simple steps to qualify for it.  And that’s exactly what most decision makers are doing.

 

Optimization consists of a 9-step process that can only be achieved with an Active or On-Going Program that follows a regiment of extract, report, analyze, plan, and act for each quarter or month. And only by taking each step can you earn exceptional Category Weights and a Final MIPS score that will qualify for the maximum payment adjustment in the next PAY.

MACRA is much more than a year-end submission exercise or a periodic measure calculation. You can’t improve performance by looking at your metrics after the year is over.  And simply making numbers available a couple times a year only improves things a little.

At times your Category Weights and MIPS score may not be complete and/or accurate. And while some solutions can be applied retroactively, many require that coders or physicians change the way they describe things, or even change physician behavior.

Many so-called MIPS or MACRA experts’ (vendors) give lip service to CMS quarterly or monthly requirement of integration and feedback. They get by with a dashboard that clients can look at any time. Such a passive approach is NOT reliable. The fact is – a dashboard is the least reliable of all.

What Else is Required

For TINs with fewer than 100 physicians & clinicians, it should be enough to run reports from your EHR quarterly, post them to a standalone MACRA database for performance analysis, and discuss shortfalls against targets.  For complex multi-TIN organizations, MACRA Optimization steps need to be done monthly.

Sophisticated program analytics is required because raw MACRA data doesn’t mean a lot to TIN management, physicians, or clinicians.  By adding the financial impact, this creates a clear frame of reference. And once CMS publishes their Physician Compare content, the MACRA team should study the impact of public scores on the flow of new patients.

Many mid-to-large sized TINs may need at least one person with the expertise, time, and resources (including access to external expertise) to maintain or achieve the highest performance status.

If you’re an ACO member or already working with a MACRA or MIPS vendor or Registry, you still need an independent 3rd party review of their work to ensure they’re following up on all requirements. Because you can’t afford to find out if they’re not after the fact.

The platform will also help you identify areas that need improvement and helping you get patients scheduled for Chronic Care conditions.

So, if you’re looking to do more than check the compliance box, the platform will allow you to turn your compliance into a competitive advantage and higher revenue by developing services in line with CMS’s Medicare CCM Program.

To learn more, see our Medicare CCM Program Optimization webpage.

Who Needs It? (Epic, Cerner, Allscripts, eClinical Works) – Almost All EHR Users

Your EHR can’t submit MACRA data directly to CMS.  In fact, it can be hard to even analyze your MACRA data in meaningful ways.  That’s why the platform subscribers get better reimbursements, with less manpower.

Physicians Buy EHR for Patient Care – Not for Fast-Moving Regulatory Compliance

Managing MACRA from a physician point of view should be a by-product.  We find that even the best EHRs only keep up with MACRA at the superficial level of creating numerator / denominator values, and honestly – those rules don’t change much.

CMS Publishes Hundreds of Pages of New MACRA Rules Each Year 

The platform relies on your EHR to do the numerator and denominator work, but does all the rest relating to those hundreds of pages.

EHR Plugin

The platform is a cloud-based tool that connects to your EHR with no local software needed.  And its enhanced reporting and sophisticated concierge team take you to the next level – beyond simple numerator / denominator content.

Whether your EHR is sophisticated enough to create QRDA3 output, a simple spreadsheet, or just a PDF – connecting to the platform simplifies connecting to CMS.

Automated Data submission

With the platform there is no need to manually submit or upload data via EIDM.  It provides an automated streaming API directly to CMS, with automated response and tracking at the level of TIN, Provider, MIPS Category and Measure.

MACRA Financial Projections

The platform automatically queries CMS for Medicare billing and payment history for each provider.  Then it applies statutory minimum / maximum expectations based on each year’s MACRA rules, adjusted for estimated CMS Scaling Factors.  It then sets budgets that tie together operational performance with financial performance.  Finally, as it accumulates PI, CQM, Cost, and CPIA data throughout the year, it displays actual financial results against these budgets.

Provider Dashboards and Scorecards

Our platform’s excellent dashboard integrates financial performance with MACRA operational performance in uniquely powerful models.   It flags individuals, TINs, and customizable groupings against operational targets throughout the year. And it provides potent provider communication tools that clearly share the impact of performance.

Analysis of Alternatives

As the platform tracks actual performance data throughout the year, you will have instant visibility into which submission models (Group / Individual, EHR / Registry, ACO / Advanced APM / Standalone) earns the greatest MACRA reimbursement.

Physician Compare / Review and Correction Cycle Management

Submission is not the end of your MACA Season. CMS ultimately will echo back their understanding of your submissions, and give you the chance to agree, or to submit data for further review.  The platform gives provider groups the tools to manage the overall process.

Complex TIN and Provider Organization Management

No one tracks complex organizations like the platform.  Its tools incorporate not only TIN dashboarding, but also identify the key workflow steps that keep track of progress across complex TIN structures.

Software + Concierge

Because the platform is independent of EHR and Registry offerings, it is in a unique position to identify, configure, and submit your very best MACRA options.  It often blends from multiple offerings, which really fine-tunes your result.

Tools and Consulting Combined

Not even the best tools stand alone.  And not even the best consultants can organize and optimize complex data.  We believe your needs include both consulting and software thoroughly integrated.

Your Concierge is always available, for help with any MACRA tasks.  The platform’s software integrates with any EHR and any Registry, to give you the best of both worlds.

In PAY 2024, CMS reports that more than 21% of all MIPS eligible TINs, physicians, and clinicians will be penalized with a negative payment adjustment.

It is estimated that up to $3.6 billion will be redistributed to 2022 top MIPS performers in 2024.

You can find your payment adjustment in your QPP Detailed Final Report. But you need to verify the payment adjustment on each claim you submit because it will not be easy to identify and will require a bit of calculation to show if it is correct. It will show as a dollar amount on your remittance advices, but to determine if it is accurate you will need to convert it to a percentage and compare it to the expected percent for the submitting physician, which will not appear on your remittance advices. Our Payment Adjustment Remittance Verification (Remittance/Value Verification) pulls the expected percent from the CMS / QPP database and compares that value to the value calculated on your TINs Remittance Advices.

Maximizing your payment adjustment begins with the MIPS Category Weights Data Analysis to determine the best course of action you need to take. This will include a Remittance/Value Verification of your payment adjustment on up to 100 of your recent claims submissions and identify the steps you’ll need to take to maximize your payment adjustment in the next PAY. A reasonable analysis fee applies.

We will utilize publicly available CMS data, and data you supply us from your QPP Detailed Final Report, ACO, Electronic Medical Records (EHR) system, Practice Management System, and/or other manual sources.

The process will take a little time and effort on your part, but we help make this as simple as possible for you. You should expect to spend an hour or two working with us to extract the data points required. The research, analysis, and final report effort will take several manhours to complete. Within two business days, we will be ready to discuss the analysis findings and recommendations with your decision makers.

Our MACRA Optimization platform is the empowering solution that will ensure you meet all requirements, improve Category Weight Scores, and maximize your payment adjustment in the next PAY.

Understanding the financial implications of the QPP & MACRA helps in making the decision on whether to invest in MACRA Optimization / Registry Services or stay the course with your ACO, vendor, or your own year-end submission very easy.

The Transfer to MVP Option

MIPS Value Pathways (MVPs) are a new, voluntary way to meet MIPS reporting requirements. Each MVP includes a subset of measures and activities that are related to a specialty or medical condition to offer more meaningful participation in MIPS.

Our team of experts will assist you through the reporting requirements, the catalog of finalized MVPs (including the measures and activities included in each MVP) and determine if there’s an MVP that’s clinically relevant for you.

To learn more, see our Transition to MVP webpage.

Take a few moments to download our supporting materials.

• 2025 CMS Final Rule (pdf).
• NQS 2024 (pdf).
• CMS Optimizing Care Delivery Framework 2025-2030 (pdf).
• Qualified Registry – A Pathway to Success within MACRA (pdf).

Our Provider Partner is a MACRA & HIE expert and CMS Certified Clinical Qualified Registry that specializes in the processes of MIPS and the QPP & MACRA for financial ROI.

They support thousands of independent and hospital-based physicians & clinicians, multi-TIN organizations, and ACO members. As a Certified Clinical Qualified Registry, they’re a CMS approved entity that collects clinical data from MIPS eligible TINs, physicians, and clinicians (both as individuals and groups) and submits it to CMS on their behalf for purposes of MIPS (reporting options are limited to measures within MIPS and the Quality Payment Program).

They possess a knowledgeable team of people that handle all necessary tasks and provide frequent reporting and useful analysis.

In a 30-60-minute Zoom call, we will review a CMS database look up that we will do on your TIN, which will show you how much more revenue and reimbursement we can help you capture, talk about the required analysis, and the easy enrollment process.

Take a moment to download our NCND. Complete and email it to: support@livewellaps.com. Then reserve your Zoom call with us.

1. Click Here to download our Mutual NCND (pdf). We are NOT data miners. Your info will be kept strictly confidential. We will also be sharing proprietary and confidential information with you on the Zoom call.
2. Click Here to go to our Calendly page to reserve your Zoom call (complete the required fields and when asked “purpose of call,” click: MACRA Optimization).