Specialists are generally subject to the MACRA merit-based incentive payment system (MIPS) in the same manner as primary care clinicians but are treated differently under MACRA in two situations:

  1. Certain specialists may qualify as “non-patient-facing” (for example, pathologists or radiologists that do generally not see patients) and have reduced MIPS reporting obligations; and
  1. A specialist who participates in more than one alternative payment model (APM) will receive the most favorable APM treatment of the APMs in which the specialist participates (for example, if the specialist participates in two Track 1 ACOs, the specialist will get the higher of the MIPS scores for those ACOs).

Physicians who fall into one of these categories have additional or different considerations than other MIPS eligible clinicians and should be sure that they are aware of the differences to maximize their reimbursement.

Non-Patient-Facing Clinician

In order to qualify as a “non-patient-facing” clinician, an individual MIPS eligible clinician must bill 100 or fewer patient facing encounters (including Medicare telehealth services) during the non-patient facing determination period. The non-patient-facing determination period actually involves analysis of two periods:

(i) an initial 12-month segment of the non-patient-facing determination period spans from the last four months of a calendar year two years prior to the performance period followed by the first eight months of the next calendar year and include a 60-day claims run out; and

(ii) The second 12-month segment of the non-patient-facing determination period would span from the last four months of a calendar year one year prior to the performance period followed by the first eight months of the performance period in the next calendar year and include a 60- day claims run out.

So, for example, for the 2019 MIPS payment adjustment, the initial segment will be from September 1, 2015, to August 31, 2016, and the second segment will be September 1, 2016, to August 31, 2017. The purpose of the two-segment approach is to let clinicians know whether they meet the non-patient facing criteria before the performance period and then to add to the list of non-patient-facing clinicians those who meet the criteria during the second segment (but didn’t do so during the first). So it will be important for clinicians who expect to be non-patient-facing to watch for the notice after the initial segment (which should be in December) and, if non-patient-facing status is not achieved, determine what measures may be put in place to ensure qualification during the second segment.

If a clinician is non-patient-facing, the clinician has reduced reporting MIPS reporting obligations in that, at least initially, reporting will comprise only two of the four performance categories:

(i) quality (85 percent of score if three or more measures reported); and

(ii) improvement activities (15 percent of score).

For quality measures, a non-patient-facing clinician should probably look for an appropriate specialty-specific measure set that may include fewer measures than the six total measures generally required for MIPS clinicians. For improvement activity performance, a non-patient-facing clinician will receive full credit by selecting one high-weighted improvement activity or two medium-weighted improvement activities or half credit for selecting one medium-weighted improvement activity. Because a non-patient-facing clinician only reports two of the four performance categories, the full MIPS score will be calculated

Multiple APM

When a specialist (or any other clinician) participates in multiple APMs, Medicare will use the highest final score to determine the MIPS payment adjustment for that MIPS eligible clinician. Notably, MIPS adjustments apply to a tax identification number (TIN) and national provider identifier (NPI) combination, so a clinician intending to qualify for the APM scoring standard will need to make sure the clinician’s NPI is associated with a TIN that is identified as an APM participant. Even if a clinician works with an APM, if the arrangement is not structured so that the clinician’s TIN and NPI are linked to the APM, the clinician will not qualify for APM scoring. The TIN may be a group TIN or the clinician’s individual TIN.

It is important for clinicians considering joining any APM to determine whether and to what extent the APM will benefit the clinician – in the context of both potential shared savings (and, if applicable, losses) and MIPS scoring under MACRA. The types of information that will be important are historical data about APM performance (if available), which will indicate how quality performance scoring may be impacted, and clinical practice improvement and advancing care information efforts of the APM (e.g. is the APM actively working with participants to enhance scores or is it entirely passive about these issues).

Managing MACRA – Part V: What do I have to do if I’m in an ACO?

Managing MACRA – Part IV: When does it begin?

Managing MACRA – Part III: What is an APM?

Managing MACRA – Part II: Does MACRA apply to me?

Managing MACRA – Part I: What is MACRA?