You may not realize it, but as of 2020 there is now only one way to increase Medicare reimbursement rates, barring Congressional intervention. Let’s review how we got here and what can be done.
In a rare instance of bipartisan support, Congress overwhelmingly passed the Medicare and CHIP Reauthorization Act (MACRA) in 2015, which effectively ended the flawed Sustainable Growth Rate formula (SGR) for determining Medicare’s physician reimbursement schedule.
The SGR for years had repeatedly forced Congress’s intervention to prevent draconian cuts to the Medicare physician fee schedule, with providers often asked to hold claims until the legislative fix was passed or submit claims for reimbursement at reduced rates, then track and wait for the claims to be adjusted once the legislation was approved.
No one practicing at the time was sad to see the SGR go. MACRA also provided for an annual Medicare physician fee schedule increase of 0.5 percent per year for every year through 2019.
Quality Payment Program (QPP)
You probably also now know that MACRA forced the Center for Medicare & Medicaid Services (CMS) to enact regulations to create a new physician payment system, called the Quality Payment Program (QPP). QPP has two options through which all Medicare providers may be paid (Figure 1):
1. The Merit-Based Incentive Payment System (MIPS), which is the default program for all providers
2. Alternative Payment Models (APMs), which have very specific eligibility criteria, of which very few specialty providers, ODs, are currently able to participate at high enough levels to qualify
Because the majority of optometrists are ineligible for APMs, let’s look at MIPS in more detail.
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