Audacious AI Blog

MACRA, Provider Contracts and Credentialling

Contract ImageThe first two years have been easy.  CMS defined MACRA that way with transitional rules designed to attain high participation, while minimizing penalties for small and rural providers.  The practical upshot has been that penalty pools are sparsely populated with the money that gets allocated to high performers.  The second upshot was that everyone has been a high performer.  

Those transitional rules are still with us, but get adjusted each year so that MACRA ultimately runs as Congress intended.  As transitional rules phase out, MACRA scores in the 90's will be no assurance of earnings, or even of penalty avoidance, and earning MACRA money will require scores in top 90's.  Turning on a few simple contract features today will protect organizational options in the upcoming years, as earning MACRA dollars gets harder, based on ultra fine tuning.  

TIN Contracts for ACOs

Some ACOs already incorporate performance metrics into contracts with their member clinics.  Because MACRA results of each clinic impact all other clinics, ACOs should incorporate new additional incentive structures that:

  1. reward participation in Monthly MACRA performance reviews; 
  2. require monthly submission of PI and CQM data from EHR; and
  3. reward clinic-level scoring above annually-set targets.  

Although ACOs do not usually receive direct revenues based on MACRA performance, we believe that ACOs are the only entity in a position to impact MACRA scores for their members.  Ultimately, providers will begin to realize this and hold ACO boards responsible for performance.  

Provider Employment Contracts

Within a clinic, individual providers have little to do with administration of MACRA.  Accordingly, individual incentives (if any) should be tied to performance against annually-set targets for overall CQM and PI performance, rather than against participation periodic meetings.  With reasonably good reporting tools, a monthly program can be tied to either category-level (CQM / PI) or measure-level scores.  

Credentialling and Provider Onboarding

When a new provider joins a clinic, that provider does not inherit the clinic's MACRA financial adjustment, but carries one along from their prior employer. This means that part of provider onboarding should be to capture each provider's prior year MIPS scores (and resulting financial adjustment percentage).  These data are available on the CMS QPP website, only after the provider has granted proxy access to the new employer.  Each year's score should be embedded into the clinic's MACRA archives, so that claims audit and reconciliation processes will have accurate basis for review. 

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MACRA Monitor is an subscription-based product from C3 Partners that combines a MACRA database with dedicated Concierge service for ACOs and other complex organizations