This article applies to the Private Practice Suite


The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) makes sweeping reforms to payments under Medicare Part B, which could lower or increase the amount your agency is reimbursed by Medicare.

The Centers for Medicare and Medicaid Services’ (CMS) Quality Payment Program has two parts: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs). Both mechanisms focus on moving from payment for volume to payment for quality and value, and non-participation will result in reductions in reimbursement. The vast majority of behavioral health organizations that bill Medicare Part B will be subject to MIPS in 2017.

What is MIPS?

MIPS collapses three existing quality reporting programs into one, while adding a fourth category:

  • The Physician Quality Reporting System (PQRS) becomes Quality under MIPS, and requires eligible clinicians to report certain quality measures on an annual basis.
  • The Value-based Payment ModifierProgram (VM) becomes Cost under MIPS. This category analyzes claims data to compare costs to treat similar care episodes and clinical condition groups across practices.
  • The Medicare Electronic Health Record (EHR) incentive program becomes Advancing Care Information under MIPS, and retains an emphasis on interoperability and information exchange.
  • A brand-new performance category is Improvement Activities, which rewards practices that engage in quality improvement activities, including for their Medicaid and other non-Medicare patient populations.

If you’re ready, you can begin January 1, 2017 and start collecting your performance data. If you’re not ready on January 1, you can choose to start anytime between January 1 and October 2, 2017. Whenever you choose to start, you’ll need to send in your performance data by April 3, 2018. The first payment adjustments based on performance go into effect on January 1, 2019.

Depending on the track of the Quality Payment Program you choose and the data you submit by April 3, 2018, your 2019 Medicare payments will be adjusted up, down, or not at all. The information provided below is only relevant for the 2019 payment year. CMS will provide additional information on payment adjustments for 2020 and beyond beginning next year.

The size of your payment adjustment will depend both on how much data you submit and your quality results

Access more information on eligibility, how to prepare, MACRA FAQ and the CMS Website.

The content of this article is reproduced with explicit permission from the National Council for Behavioral Health. The content was retrieved on November 18, 2016. Please visit the National Council for Behavioral Health for updated materials.

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