On this page we compiled a number of resources around MACRA and implications for FQHCs. Before outlining the resources we first provide an overview of the Quality Payment Program. The Quality Payment Program under MACRA includes two tracks: Advanced Alternative Payment Models (APMs) or Merit-based Incentive Payment System (MIPS).
Advanced Alternative Payment Models (APMs)
To qualify as an APM under MACRA, a model generally must use Certified EHR Technology, report quality measures comparable to measures under MIPS, and bear financial risk in excess of a nominal amount. Participants in APMs will receive a lump sum payment from Medicare in the amount equal to 5% of last year’s fee for service payments.
FQHC visits may be able to count toward a Qualified APM Participant’s patient count and thus a participating FQHC could be eligible for the “bonus payments” in an APM model. Additional details are to be determined at the APM level and subject to CMS approval.
Merit-Based Incentive Payment System (MIPS)
Those providers paid on the Physician Fee Schedule who do not participate in a qualifying Advanced APM must participate in MIPS. According to CMS and NACHC, clinicians billing under the RHC or FQHC payment methodologies are not subject to the MIPS payment adjustment.
However, clinicians in a RHC or FQHC billing under the Physician Fee Schedule (PFS) – services billed outside of the FQHC benefit and billed to Medicare Part B separately – are required to participate in MIPS and are subject to a payment adjustment if they exceed the low-volume threshold. The low-volume threshold is defined as healthcare professionals that have Medicare Part B billing charges that are less than or equal to $30,000 OR provide care for 100 or fewer Part B-enrolled Medicare beneficiaries.
FQHCs may choose to voluntarily submit quality data to CMS to prepare for future participation, but they will not qualify for a payment adjustment based on your 2017 performance. Voluntarily participating will help you hit the ground running when you are eligible for payment adjustments in future years.