Re-Evaluating the Role of RCM for MACRA Success

It’s hard to believe we’re already well into the latter half of the first Medicare Access and CHIP Reauthorization Act (MACRA) reporting year. With the clock ticking, pressure continues to mount for physician organizations to close the inaugural year with strong momentum before 2018. Although CMS recently proposed several changes that may make Year 2 of the MACRA Quality Payment Program (QPP) less challenging for some providers, it could be more demanding for other organizations.

For Year 1, healthcare leaders identified “revising data management/reporting mechanisms to meet new reporting requirements” as the top QPP challenge within the fifth annual Healthcare IT Industry Outlook Survey. That difficulty is unlikely to change for 2018. Because the QPP ties provider reimbursement incentives to care quality, improvement activities, costs and electronic health record (EHR) utilization, alignment has been critical this year, but will be especially crucial moving into 2018. Given that, what opportunities can the revenue cycle management (RCM) team take advantage of to improve their MACRA performance for the remainder of this year into next?

Assembling the Right Team

Traditionally, provider organizations have focused reporting needs on claims and reimbursement data, working within separate data silos, disconnected from associated facilities. In the transition to value-based care, they’re finding it more imperative to work cohesively across three key resource groups to access and obtain the right data for MACRA needed to attain positive or even neutral adjustments to reimbursement.

Providers need to form a strategic cross-disciplinary team including representation from financial, clinical and operational IT departments to maximize access to the right data across the patient-care continuum. Considering the two reporting paths, either Advanced Alternative Payment Models (APMs) or Merit-based Incentive Payment System (MIPS), the revenue cycle representatives on the committee can offer key insights into program measure selection.

In fact, RCM representation is so critical that one might argue that successful MACRA strategy cannot move forward without it. This financial team offers specific insight into which MACRA measures to select, by tapping into their knowledge of values and performance from past physician incentive reporting programs. For example, historical data from the Physician Quality Reporting Program (PQRS) and the Value Based Payment Modifier (VBPM) can point to which measures offer the highest potential for positive reimbursement adjustments. The QPP provides options of measures to report within each category, and the right scoring criteria can make a big difference in reporting success.

Making the Most of MACRA
With RCM representation as a critical decision maker, consider utilizing theses best practices to excel with MACRA QPP reporting.

  • Get the basics. Get a solid understanding of the QPP and the two path options. Consider the best reporting measures from the full set of options for your organization. Utilize industry resources like the Centers for Medicare & Medicaid Services (CMS) QPP measure guide for your pick-your-pace reporting to avoid penalty before the first year ends.
  • Use your physician group’s medical specialties mix to your advantage. Many program measures are focused on specific population health concerns, which may relate to some medical specialties more heavily than others. If your providers already have specific-focus care programs for one of the chronic disease groups, attaining key measures for those may be easier.
  • Check out helpful resources. CMS released several resources for MIPS-eligible clinicians through the QPP. The MIPS participation factsheet covers program exemptions, participant expectations and guidelines. CMS-approved MIPS qualified registries serve as a data submission option on behalf of both individual and groups of eligible clinicians.
  • Look ahead into expanded exemptions. QPP year 2’s leniencies relieve small and rural practices by expanding exemption threshold to cover clinicians or groups who have billed less than $90,000 in Medicare Part B or treat fewer than 200 Part B patients. Your RCM staff should be able to determine quickly if your practice is below this threshold.
  • Set the foundation. MACRA reporting is lost without accurate data. Data analytics tools can work with optimized EHR systems to effectively collect, maintain, document and analyze meaningful patient data, moving beyond the abyss of unstructured information and capturing the entire picture of patient care. Likewise, while providers can continue using 2014 certified EHR technology (CEHRT) for MIPS Year 2, those who use 2015 CEHRT are eligible for a 10 percentage point bonus under the ACI category.
  • Know where you stand. If you submitted quality data in the last calendar year, consider your Quality and Resource Use Report (QRUR) from CMS, which analyzes performance at the Tax Identification Number (TIN) level. Reviewing this will help you assess performance in terms of cost and quality to consider areas to improve. Aspects of this report, like PQRS and Value-Based Payment Modifier, are rolled into MACRA. In addition the QRUR will highlight your physicians ranking among their peers to give you added insight into how forecasting will impact reimbursement as the reporting year unfolds.
  • Ensure accurate coding. Make sure billers and coders fully assess the coding system to find inaccuracies, looking for risks like downcoding or missing modifiers that can impact the overall picture of care and revenue opportunity. The importance of this type of post-care analysis cannot be overstated as these steps can dramatically alter a physician’s composite score.
  • Use 2017 to solidify footing. Reporting requirements will only accelerate after 2017. Although the pick-your-pace guideline applies this year, 2018 requires a full year of data for both the quality and cost categories (though cost has no weight on the final score). An organization should use this initial reporting year to reassess performance improvement measures while cementing its MACRA governance committee for long-term success. Under MIPS, adjustments to reimbursement and/or penalty opportunity increases to 9 percent by 2022, so use this first year as a jumping point.
  • Consider future path options. While most organizations may report under MIPS within this first year, they don’t necessarily have to follow suit in future reporting periods. With the insight from financials, decide whether MIPS or APMs reporting best fits long-term stability and growth.
  • Explore virtual groups. An addition to the QPP for Year 2 is virtual-group participation in MIPS. Virtual groups consist of solo practitioners and groups comprised of 10 or fewer MIPS-eligible clinicians coming together virtually for 2018 performance participation with at least one other solo practitioner or group. Your RCM staff is integral in deciding if a virtual group will be financially advantageous for the practice in Year 2 and afterwards.
  • Evaluate future composition of physician groups. Change is constant within the overall composition of physician groups, both from the perspective of new additions or that of attrition. Managers need to consider this financial perspective for impact on MACRA reporting since there is a two-year gap between financial reporting and reimbursement adjustments. QPP final scores will impact providers beyond reimbursement as physician scores will be published online and shared on third-party sites.

So whether you are beginning your MACRA reporting path, moving through strategic planning or in the midst of data collection, consider the significance of RCM on QPP reporting alignment and success, including governance leadership and insight into operational effectiveness. Without financial entities at the MACRA decision-making table, the full picture of reporting measure selection and outcomes cannot be seen.


MACRA, RCM, Revenue Cycle Management


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