A Glossary of Must-Know Medicare Terms

It’s been a few years since we revisited the hodgepodge of acronyms that comprise the Centers for Medicare and Medicaid Service’s (CMS) Medicare Access and CHIP Reauthorization Act, the initiative that seeks to replace the traditional fee-for-service model with one that places greater value on quality of care. Here’s an easy-to-understand glossary of key terms. Your practice’s financial future may depend on how well you understand these terms and comply with the regulations they represent.

APM: ALTERNATIVE PAYMENT MODELS

An APM is one of two new provider payment pathways under MACRA’s Quality Payment Program (QPP). An example is Medicare Shared Savings Plan (MSSP), also known as an Accountable Care Organization (ACO). Under this APM, a share of the cost savings is passed on to the practice if it provides high-quality/low-cost care to a defined group of Medicare beneficiaries. There are many types of APMs with more being developed and tested. There are also advanced APMs that must meet other requirements, such as bearing a significant financial risk for even greater rewards.

CMMI:THE CENTER FOR MEDICARE And MEDICAID INNOVATION

This is Mecca for all things MACRA. The Center supports the development and testing of innovative healthcare payment and service delivery models, such as APMs, and alerts interested doctors about which programs are currently enrolling or up and running.

EHR: ELECTRONIC HEALTH RECORD

An EHR is a digital version of a paper chart, and the adoption and meaningful use of EHRs is central to the pursuit of value-based care and payment.

IA: IMPROVEMENT ACTIVITIES

Improvement activities (IA) represent a brand new reporting category for MIPS. Examples include 24/7 access to clinician coupled with real-time access to medical records, completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course, or acting as a preceptor for clinicians-in-training. Practices need a certain amount of IAs to avoid a penalty and even more to earn an incentive payment through MIPS.

MACRA: MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015

MACRA attempts to shift physician payment so that it rewards value and quality over volume, via the Quality Payment Program, which offers two pathways for reimbursement: Merit-based Incentive Payment System (MIPS) (see below) and APMs (see above).

MIPS: MERIT-BASED INCENTIVE PAY SYSTEM

Sired by MACRA, MIPS determines physician payment penalties and bonuses based on their reporting of quality metrics and the resulting MIPS performance score. MIPS comprises the former Physician-Value Based Payment Modifier (VBM), Physician Quality Reporting System (PQRS), and the Medicare EHR Incentive Program.

PI: PROMOTING INTEROPERABILITY

Interoperability is the holy grail of health information technology. It is defined as the extent to which systems and devices can exchange data and interpret that shared data, according to the Healthcare Information and Management Systems Society. The Promoting Interoperability (PI) MIPS category encourages clinicians to adopt, implement and use EHR technology.

QCDR: QUALITY CLINICAL DATA REGISTRY

QCDR is a CMS designation that allows users to report many MIPS measures in addition to other clinical data that can improve patient care and lead to the betterment of a specialty or the greater good. The AADs DataDerm is an example of a QCDR.

QPP: QUALITY PAYMENT PROGRAM

The bread and butter of MACRA offers doctors two pathways for reimbursement: MIPS and APMs.