macra-hero-01-4cf07b43798bOn October 14, 2016, CMS released its final rule for the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act (MACRA). Federally Qualified Health Centers and Rural Health Centers have asked if MACRA applies to them. The answer is a bit complicated.

The MACRA Final Rule makes clear that FQHC and RHC services billed under the global or all-inclusive rate are not subject to the Merit-Based Incentive Payment System (MIPS) payment adjustments. (See below.) Many FQHCs and RHCs do bill some services such as lab and portions of radiology services under Medicare Part B. Because of this, some have received penalty notices for not participating in PQRS, and therefore, they are worried they will continue to get penalties under MACRA and MIPS. The good news is that, unlike PQRS, MACRA has a low volume exclusion that may exempt those FQHCs and RHCs from MIPS payment adjustments for their Medicare Part B payments. CMS does encourage FQHCs and RHCs to participate voluntarily, if they desire to do so.

From page 46 of the MACRA Final Rule pdf in the Federal Register (or page 77053):
…Services rendered by an eligible clinician under the RHC or FQHC methodology will not be subject to the MIPS payments adjustments. However, these eligible clinicians have the option to voluntarily report on applicable measures and activities for MIPS, in which the data received, will not be used to assess their performance for the purpose of the MIPS payment adjustment.

Decision Tree Analysis
If an FQHC or RHC bills Medicare Part B for some services, it may be subject to MACRA’s provisions, however. For instance, RHCs must look at how much traditional Medicare Part B is billed using a 1500 claim form (versus the all-inclusive rate). FQHCs must look at whether they bill Medicare Part B for some office procedure components, such as EKGs, pulmonary function tests, Holter monitors and some radiology services. So, how does an FQHC or RHC decide what to do? Please consider the following questions in deciding what course is best for your FQHC or RHC:

1. How much do you bill Medicare Part B in a year? Could you be exempt due to a low volume threshold?
– If less than $30K or 100 pts for the whole group/tax payer ID (TIN), then no MIPS participation required. RHC or FQHC as a group meets low volume exemption.
– If more than $30K or 100 patients, go to question 2.

2. Could the Medicare low volume threshold apply to your individual clinicians?
– Is it possible that individual clinicians meet the low volume threshold and will be exempt from MIPS? Be sure to exclude non-patient facing and first year providers for calculations as they are exempt from MIPS.
– Example: Seven eligible clinicians in an FQHC are a part of the same TIN and each bills less than $10,000 in Medicare Part B charges. The group together exceeds the low volume threshold. However, CMS will also look at individual clinician billing and so they will likely be excluded.

3. If the FQHC or RHC’s clinicians are not exempt from MIPS, then consider: will the 4% penalty for non-participation in the first year harm your financial health? Or will paying staff or IT costs needed for MIPS be worth it to avoid the penalty? If the revenue is substantial and patients like the convenience of labs, radiology and other services being performed on site, it may be worth it to participate in MIPS.

4. When in doubt, consider using Option 1 in 2017: report something under MIPS. CMS has made it extremely easy to report and avoid penalties in the first year.

Who determines which groups or clinicians meet the low volume exclusion?
CMS will review Part B claims and make a determination whether groups and individual clinicians are excluded due to low volume. CMS intends to provide a NPI level lookup feature that will allow clinicians to know whether they are excluded from MIPS. For more information, see the Low Volume Threshold section of the Final Rule beginning on page 220 for more information.

What if RHCs or FQHCs are in APMs?
Certain FQHCs or RHCs may have “qualifying providers” (QPs) in advanced Alternative Payment Models (APMs) such as a Medicare Shared Savings Program Track 2 or Track 3 Accountable Care Organizations. These QPs may be eligible for additional bonuses under MACRA. For more information, see the following sections from page 451 of the pdf or page 77458 of the Federal Register version of the MACRA Final Rule:

CMS proposed that beneficiaries in RHCs and FQHCs that participate in ACOs, and that are reimbursed under the RHC AIR or FQHC PPS be counted towards the QP determination calculations under the patient count method but not under the payment amount method…Beneficiary will be included in the numerator of the Threshold Score for the patient count method if the beneficiary receives…professional services furnished by eligible clinicians in an Advanced APM Entity at RHCs and FQHCs.

More questions? Contact UK’s Kentucky REC at 859-323-3090.