MACRA Proposed Rule for 2018

Nathan Baugh, Director of Government Affairs


MACRA Proposed Rule for 2018

Last week, CMS released their 1,050 page MACRA proposed rule for calendar year 2018.

The big proposed change is an increase in the low-volume threshold for participation in MIPS to $90,000 (up from $30,000) of Medicare allowable revenue or 200 (up from 100) Medicare part B patients. This proposed change should exempt most RHC clinicians from the MIPS program.


As a refresher, MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015 and it is the underlying law behind the Quality Payment Program (QPP) which establishes two new payment tracks for eligible clinicians: the Merit Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). These new payment systems are designed to reward eligible clinicians (physicians, PAs and NPs) for the value of their care.

MIPS rewards clinicians who achieve high (CPS) Composite Performance Scores with bonus payments, and penalizes clinicians with poor CPS scores.

RHC payments are exempt from MIPS because the program only affects payments made under the Medicare Physician Fee Schedule (PFS). As you know, RHCs are paid on a cost basis through the RHC All-Inclusive Rate and bill on a UB-04 form. However, many RHCs bill for so-called “non-RHC services” on a CMS-1500 to a Medicare Part B MAC. These claims are potentially subject to MIPS payment adjustments if a clinician has enough “PFS” revenue/patients. However, CMS is now proposing a higher low-volume threshold that would exempt most clinicians and almost all RHC practitioners from participation in MIPS.

Clinicians can participate in MIPS individually, as a group (if the eligible clinician belongs to a group), or as a virtual group (individuals or several groups joining together for the purposes of a MIPS CPS score). Applicability of the low-volume threshold depends on the reporting entity. For example:

Consider three clinicians in a group practice. Each clinician has $50,000 of Medicare allowable revenue. If CMS finalizes the low-volume threshold as proposed, the clinicians would be exempt from MIPS in 2018 if they report individually. However, if they report as a group, they would all be eligible for a MIPS CPS score because, together, they have $150,000 of total allowable Medicare revenue.


One other way to avoid MIPS adjustments, is to participate in an Advanced APM. These are payment models that incorporate EHR standards, quality metrics, and have some financial risk to the provider. Clinicians who participate in an Advanced APM receive a lump sum incentive payment of 5% based on their PFS revenue. Any revenue generated through an RHC (or UB-04) claim, would not count towards this lump sum bonus.

The arrangements and details of each Advanced APM are too complicated for the purposes of this email. However, you may research more about Advanced APMs HERE.


The proposed rule is open for public comment until July 23rd. Once the public comment period ends, CMS will review all comments and potentially make changes in the proposal prior to the issuance of the final rule. CMS expects to issue the final rule in early November.

Nathan Baugh
Director of Government Affairs
(202) 544-1880