MACRAnyms1: Acronyms and Terms Related to MACRA

Acronym What It Stands For Definition

Acronym

MACRA

What It Stands For

Medicare Access and CHIP Reauthorization Act

Definition

The Medicare Access and CHIP Reauthorization Act (MACRA) is landmark legislation that makes three important changes to how Medicare pays physicians who provide care to traditional Medicare beneficiaries. These changes include: repealing the sustainable growth rate (SGR) formula for determining Medicare payments for health care clinicians’ services; creating a new framework for rewarding health care clinicians for giving better care; and combining existing quality reporting programs into one new system.

See also: Sustainable Growth Rate (SGR), Medicare, Children’s Health Insurance Program (CHIP)

Acronym

CMS

What It Stands For

Centers for Medicare & Medicaid Services

Definition

Part of the Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) manages the administration of Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace.

See also: Medicare, Medicaid, Children's Health Insurance Program (CHIP), Health and Human Services (HHS)

Acronym

HHS

What It Stands For

Health and Human Services

Definition

Health and Human Services (HHS) is the department of the U.S. federal government whose mission is to enhance and protect the health and well-being of all Americans. HHS has 11 operating divisions that include the Centers for Medicare & Medicaid Services (CMS).

See also: Physician-focused Payment Model Technical Advisory Committee (PTAC)

Acronym

What It Stands For

Medicare

Definition

Medicare is a federally administered health insurance program for people 65 or older, people under 65 with certain disabilities, and people of all ages with end-stage renal disease (ESRD).

Acronym What It Stands For

Medicaid

Definition

Medicaid is a national health insurance program for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Unlike Medicare, Medicaid is administered at the state level.

Acronym

MIPS

What It Stands For

Merit-based Incentive Payment System

Definition

The Merit-based Incentive Payment System (MIPS) is one of two new payment tracks established by MACRA that combines aspects of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program (Meaningful Use). MIPS consolidates these Medicare initiatives into a single program based on: quality, cost, advancing care information (meaningful use), and adds a new category called improvement activities which is based on the medical home.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Physician Quality Reporting System (PQRS), Advancing Care Information (ACI), Value-based Payment Modifier (VBPM), Improvement Activities (IA), Meaningful Use (MU)

Acronym

APM

What It Stands For

Alternative Payment Model

Definition

An Alternative Payment Model (APM) is a new approach to paying for medical care through Medicare that incentivizes quality and value. As defined by the law, APMs include: the Centers for Medicare & Medicaid Services’ Innovation Model (CMMI), Medicare Shared Savings Program (MSSP), demonstration under the Health Care Quality Demonstration Program, or a demonstration required by federal law.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Medicare Shared Savings Program (MSSP), Advanced Alternative Payment Model (AAPM)

Acronym

AAPM

What It Stands For

Advanced Alternative Payment Model

Definition

An Advanced Alternative Payment Model (AAPM) is an APM that has met the statutory APM requirements, as well as three additional criteria: (1) the APM must require participants to use certified EHR technology, (2) the APM must provide payment for covered services based on quality measures comparable to those in the quality performance category under MIPS, (3) the APM must either require APM entities to bear risk for monetary losses of more than a nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. The primary care AAPMs for the 2017 performance period include:

Comprehensive Primary Care Plus (CPC+);

Medicare Shared Savings Program (MSSP) Tracks 2 and 3;

Next Generation Accountable Care Organization (ACO); and

The Vermont ACO Initiative (as part of the Vermont All-Payer ACO Model).

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Medicare Shared Savings Program (MSSP), Alternative Payment Model (AAPM), Nominal Risk, Comprehensive Primary Care Plus (CPC+), Alternative Payment Model (APM) Entity, Next Generation Accountable Care Organization (ACO)

Acronym

AAPM

What It Stands For

Other Payer Advanced Alternative Payment Model

Definition

Other Payer Advanced Alternative Payment Models (AAPMs) include payment arrangements under any payer other than traditional Medicare. Medicare Advantage and other Medicare-funded private plans are categorized as a payer other than traditional Medicare. To be considered an Other Payer AAPM, the arrangement must meet the following criteria:

Use of certified EHR technology;

Quality measures comparable to measures under the Merit-based Incentive Payment System (MIPS) quality performance category; and

The APM entity must bear more than nominal financial risk or, for beneficiaries under title XIX, is a medical home in a Medicaid Medical Home Model meeting the criteria to Medical Home Models expanded under section 1115A(c) of the Act.

The other payer AAPM option will be available beginning in payment year 2021 (performance period 2019).

See also: Advanced Alternative Payment Model (AAPM), Merit-based Incentive Payment System (MIPS), Alternative Payment Model Entity (APM), Medicare Part B, Medicare Part C

Acronym

MIPS APM

What It Stands For

Merit-based Incentive Payment System Alternative Payment Model

Definition

A Merit-based Incentive Payment System Alternative Payment Model (MIPS APM) includes APMs that did not meet the criteria to be considered an Advanced APM (AAPM). All AAPMs can be MIPS APMS, but not all MIPS APMs are Advanced APMs. MIPS APMs do not qualify as AAPMs because they either: do not meet the nominal risk criteria, or the AAPM participants do not meet the payment or patient thresholds. MIPS APM participants will be assessed using the APM scoring standard. For the 2017 performance period, MIPS APMs include:

Medicare Shared Savings Program (MSSP) Tracks 1, 2, and 3;

Next Generation ACO;

Comprehensive Primary Care Plus (CPC+); and

The Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO

Model).

See also: APM Scoring Standard, Medicare Shared Savings Program, Next Generation ACO, Comprehensive Primary Care Plus (CPC+)

Acronym

APM

What It Stands For

Alternative Payment Model (APM) Scoring Standard

Definition

The APM scoring standard is used for MIPS-eligible clinicians participating in MIPS APMs. The APM scoring standard will also be applied to partial qualifying APM participants who have elected to participate in MIPS. Under the APM scoring standard, the weights of the performance categories may be different than the generally applicable weights for MIPS-eligible clinicians. A MIPS final score will be aggregated at the APM entity level based on scores of MIPS-eligible clinicians in the APM entity.

See also: Merit-based Incentive Payment System Alternative Payment Model (MIPS APM), Alternative Payment Model (APM), Alternative Payment Model (APM) Entity, Final Score, Merit-based Incentive Payment System (MIPS), Eligible Clinician (EC), Partial Qualifying APM Participant

Acronym

QPP

What It Stands For

Quality Payment Program

Definition

The Quality Payment Program (QPP) is the umbrella term used to describe the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs).

See also: Merit-based Incentive Payment System (MIPS), Advanced Alternative Payment Model (AAPM)

Acronym

EC

What It Stands For

Eligible Clinician

Definition

An eligible clinician (EC) is an individual physician or health care provider who is eligible to participate in, or is subject to, mandatory participation in a Medicare program. For the purposes of the Merit-based Incentive Payment System (MIPS), an EC for years one to two of the program includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS)

Acronym What It Stands For

Pick Your Pace

Definition

Established for the 2017 performance period, Pick Your Pace provides four options for eligible clinicians to avoid the 2019 negative payment adjustment under Quality Payment Program (QPP). The reporting options to avoid the negative payment adjustment include:

Test: Submit data for one quality measure, OR one improvement activity, OR the required advancing care information measures.

Partial Participation: Submit data for a minimum of 90 days on more than one quality measure, OR more than one improvement activity, OR more than the required advancing care information measures.

Full Participation: Submit data for at least 90 days or up to a full calendar year for all of the required quality measures, all of the required improvement activities, AND all of the required advancing care information activities.

Advanced Alternative Payment Model (AAPM): Participate in an AAPM and meet the requirements to receive the 5% bonus.

See also: Merit-based Incentive Payment System (MIPS), Advanced Alternative Payment Model (AAPM), Eligible Clinician (EC)

Acronym What It Stands For

Low-volume Threshold

Definition

The low-volume threshold is set by the Centers for Medicare & Medicaid Services (CMS). Any clinician falling below is excluded from the Merit-based Incentive Payment System (MIPS) payment adjustments. To fall below the low-volume threshold, an eligible clinician (EC) must have Medicare Part B billing charges of less than or equal to $30,000 OR provide services to 100 or fewer unique Medicare Part B beneficiaries during the performance period.

See also: Merit-based Incentive Payment System (MIPS), Medicare Part B

Acronym What It Stands For

Small Practice

Definition

A small practice is defined by the Medicare Access and CHIP Reauthorization Act (MACRA) law as a practice with 15 or fewer clinicians.

Acronym

MU

What It Stands For

Meaningful Use

Definition

Established in 2011, the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs were established to encourage eligible professionals and eligible hospitals to adopt, implement, upgrade (AIU), and demonstrate meaningful use (MU) of certified EHR technology

(CEHRT). The last year to begin participation and receive incentive payments in the Medicare program was 2014. The final year to begin participation under the Medicaid program was 2016. The Medicare EHR Incentive Program formally ended at the close of the 2016 performance period and the last payment adjustment will occur in 2018.

See also: Certified Electronic Health Record Technology (CEHRT)

Acronym

ACI

What It Stands For

Advancing Care Information

Definition

Advancing care information (ACI) is a performance category under the Merit-based Incentive Payment System (MIPS) requiring the meaningful use of electronic health record (EHR) technology.

See also: Merit-based Incentive Payment System (MIPS)

Acronym What It Stands For

Base Score (Advancing Care Information)

Definition

The base score makes up 50% of the advancing care information (ACI) performance category score. An eligible clinician (EC) must report a numerator and denominator for all required measures specified in the ACI category.

See also: Advancing Care Information (ACI), Eligible Clinician (EC)

Acronym What It Stands For

Performance Score (Advancing Care Information)

Definition

The performance score allows an eligible clinician (EC) to achieve additional percentage points above the base score in the advancing care information (ACI) performance category. An EC's performance on measures for patient electronic access, coordination of care through patient engagement, and health information exchange can contribute an additional 50 percentage points to the clinician's base score.

See also: Base Score, Advancing Care Information (ACI), Eligible Clinician (EC)

Acronym

CEHRT

What It Stands For

Certified Electronic Health Record Technology

Definition

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have established standards and other criteria for structured data that electronic health records (EHRs) must use in order to qualify for the EHR Incentive Program. To earn an incentive payment, you must use an EHR that is certified specifically for the EHR Incentive Programs. Certified EHR technology (CEHRT) gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also assures clinicians and patients the

electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.

See also: Meaningful Use (MU), Advancing Care Information (ACI)

Acronym

PQRS

What It Stands For

Physician Quality Reporting System

Definition

The Physician Quality Reporting System (PQRS) was a quality reporting program that encouraged individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. Performance reports were available through the physician feedback reports and Quality and Resource Use Report (QRUR). PQRS formally ended at the close of the 2016 performance year and the last payment adjustment will occur in 2018.

See also: Value-based Payment Modifier (VBPM), Quality and Resource Use Report (QRUR)

Acronym

VBPM

What It Stands For

Value-based Payment Modifier

Definition

The budget-neutral Value-based Payment Modifier (VBPM) program provided for differential payment under the Medicare physician fee schedule (PFS) to a physician or group of physicians based upon the quality of care compared to the cost of care furnished to Medicare fee-for-service (FFS) beneficiaries during a performance period. Also called the Value Modifier (VM), the VBPM was separate from the payment adjustment under the Physician Quality Reporting System (PQRS). Performance information was available in the Quality and Resource Use Report (QRUR). The VBPM reporting formally closed at the end of the 2016 performance year and the last payment adjustment will occur in 2018.

See also: Physician Quality Reporting System (PQRS), Quality and Resource Use Report (QRUR)

Acronym What It Stands For

Measure Benchmark

Definition

A measure benchmark is the level of performance on measures a Merit-based Incentive Payment System (MIPS) eligible clinician (EC) will be assessed against. Quality benchmarks have a two-year look back and cost benchmarks are from the performance period.

See also: Merit-based Incentive Payment System (MIPS)

Acronym

What It Stands For

Topped-out Measures

Definition

A measure may be considered topped out if the measure performance is so high and unvarying that meaningful distinctions and improvements

in performance can no longer be made.

Acronym What It Stands For

Final Score

Definition

The final score is the aggregate of an eligible clinician's (EC's) scores in the four performance categories (quality, cost, advancing care information, improvement activities). The final score will be compared to a Merit-based Incentive Payment System (MIPS) performance threshold. An EC’s payment adjustment will be determined based on his/her final score.

Acronym What It Stands For

Exceptional Performance

Definition

Eligible clinicians (ECs) who meet or exceed the additional performance threshold have achieved exceptional performance. These ECs will be eligible for an additional positive payment adjustment under the Merit-based Incentive Payment System (MIPS). The maximum exceptional performance payment adjustment is 10% and will be made on a sliding scale based on performance. The adjustment falls outside of the budget neutrality requirements of the Merit-based Incentive Payment System (MIPS) adjustments and is only available from 2019 to 2024.

See also: Additional Performance Threshold

Acronym

IA

What It Stands For

Improvement Activities

Definition

Improvement activities (IA) is a performance category under the Merit-based Incentive Payment System (MIPS). IAs are identified as improving clinical practice or care delivery that, when effectively executed, are likely to result in improved outcomes. IA categories include:

Expanded practice access;

Population management;

Care coordination;

Beneficiary engagement;

Patient safety and practice assessment;

Participation in an Alternative Payment Model (APM);

Achieving health equity, integrated behavioral, and mental health; and

Emergency preparedness and response.

A certified patient-centered medical home (PCMH) will automatically receive full credit in the IA performance category of the MIPS.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), Alternative Payment

Model (APM), Patient-centered Medical Home (PCMH)

Acronym

PCMH

What It Stands For

Patient-centered Medical Home

Definition

A patient-centered medical home (PCMH) is a model or philosophy of primary care that is patient centered, comprehensive, team based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages clinicians and care teams to meet patients where they are, from the simplest to the most complex conditions. All certified PCMHs will receive full credit in the improvement activities (IA) performance category of the Merit-based Incentive Payment System (MIPS).

See also: Improvement Activities (IA), URAC, Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), National Committee for Quality Assurance (NCQA)

Acronym

ACO

What It Stands For

Accountable Care Organization

Definition

Accountable care organizations (ACOs) are groups of doctors, hospitals, and other health care clinicians who come together voluntarily to give coordinated, high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

See also: Medicare Shared Savings Program (MSSP), Next Generation ACO

Acronym

QP

What It Stands For

Qualifying Advanced Alternative Payment Model (AAPM) Participant

Definition

A qualifying Advanced Alternative Payment Model (AAPM) participant (QP) is an eligible clinician (EC) who receives a percent of their payments or sees a percent of their patients through an AAPM. A qualifying participant (QP) is eligible to receive the 5% lump sum bonus and is excluded from the Merit-based Payment System (MIPS) payment adjustments. The required percentage of payments received or patients seen increases as the program progresses. Initially, a provider must receive at least 25% of their Medicare payments or see 20% of patients through the Advanced APM entity. Beginning in 2021, a provider can meet the threshold through a combination of Medicare and other non-Medicare payer arrangements. QP status is determined

at the group level.

See also: Eligible Clinician (EC), Merit-based Incentive Payment System (MIPS), Attributed Beneficiary, Attribution-Eligible Beneficiary, Threshold Score, Advanced Alternative Payment Model (AAPM), Advanced Alternative Payment Model (AAPM) Entity

Acronym

Partial QP

What It Stands For

Partial Qualifying Advanced Alternative Payment Model (AAPM) Participant

Definition

A partial qualifying Advanced Alternative Payment Model (AAPM) participant (QP) is an eligible clinician (EC) who participates in an AAPM, but has not met the payment or patient threshold to be considered a qualifying AAPM participant (QP). A partial QP is not eligible to receive the 5% lump sum bonus and can elect to participate in the Merit-based Incentive Payment System (MIPS). In payment years 2019 and 2020, to be considered a partial QP, an EC must receive 20% of payments or see 10% of patients through an Advanced APM entity.

See also: Eligible Clinician (EC), Merit-based Incentive Payment System (MIPS), Attributed Beneficiary, Attribution-eligible Beneficiary, Threshold Score, Qualifying Alternative Payment Model (APM) Participant (QP), Alternative Payment Model (APM), Advanced Alternative Payment Model (AAPM), Advanced Alternative Payment Model (AAPM) Entity

Acronym

MSSP

What It Stands For

Medicare Shared Savings Program

Definition

Congress created the Medicare Shared Savings Program (MSSP) to facilitate coordination and cooperation among clinicians to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs. Eligible clinicians, hospitals, and suppliers may participate in the MSSP by creating or participating in an accountable care organization (ACO). The MSSP will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary. The Centers for Medicare & Medicaid Services (CMS) has designated MSSP Tracks 2 and 3 as Advanced Alternative Payment Models (AAPMs).

See also: Advanced Alternative Payment Model (AAPM), Accountable Care Organization (ACO)

Acronym What It Stands For

Next Generation Accountable Care Organization (ACO)

Definition

The Next Generation Accountable Care Organization (ACO) builds on the Pioneer model by setting predictable financial targets and offers greater opportunities to coordinate care. The goal of the Next Generation ACO model is to test whether strong financial incentives for the ACO, coupled with better patient engagement and care management, can improve health outcomes and lower expenditures for beneficiaries. The Centers for Medicare & Medicaid Services (CMS) has designated Next Generation ACO as an Advanced Alternative Payment Model (AAPM).

See also: Advanced Alternative Payment Model (AAPM), Accountable Care Organization (ACO)

Acronym

CPC

What It Stands For

Comprehensive Primary Care Initiative

Definition

The Comprehensive Primary Care (CPC) initiative was a four-year multi-payer initiative designed to strengthen primary care. The Centers for Medicare & Medicaid Services (CMS) collaborated with commercial and state health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “comprehensive” primary care functions. These five functions are:

Risk-stratified care management;

Access and continuity;

Planned care for chronic conditions and preventive care;

Patient and caregiver engagement; and

Coordination of care across the medical neighborhood.

The initiative was testing whether provisions of these functions at each practice site—supported by multi-payer payment reform, the continuous use of data to guide improvement, and meaningful use (MU) of health information technology—could achieve improved care, better health for populations, lower costs, and inform future Medicare and Medicaid policy.

See also: Center for Medicare and Medicaid Innovation (CMMI), Comprehensive Primary Care Plus (CPC+)

Acronym

CPC+

What It Stands For

Comprehensive Primary Care Plus

Definition

The Comprehensive Primary Care Plus (CPC+) is a five-year advanced primary care model that aims to strengthen primary care through regionally-based, multi-payer reform and care delivery transformation. CPC+ began in 2017, and includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the U.S. CPC+ will provide practices with a learning system, as well as actionable patient-level cost and utilization data feedback to guide decision making. Practices in both tracks will make changes in the way they deliver care, centered on key Comprehensive Primary Care (CPC) functions. The Centers for Medicare & Medicaid Services (CMS) has designated CPC+ as an Advanced Alternative Payment Model (AAPM).

See also: Advanced Alternative Payment Model (AAPM), Center for Medicare and Medicaid Innovation (CMMI), Comprehensive Primary Care (CPC)

Acronym What It Stands For

Accountable Care Organization Track 1 Plus (ACO Track 1+)

Definition

The Medicare Accountable Care Organization Track 1 Plus, (ACO Track 1+) is based on the Medicare Shared Savings Program (MSSP). ACO Track 1+ incorporates more limited downside risk than is currently present in MSSP Tracks 2 and 3. CMS has designated ACO Track 1+ as an Advanced Alternative Payment Model (AAPM) beginning with the 2018 performance period.

See also: Advanced Alternative Payment Model (AAPM), Accountable Care Organization (ACO)

Acronym

CMMI

What It Stands For

Center for Medicare and Medicaid Innovation

Definition

The Center for Medicare and Medicaid Innovation (CMMI) was created as part of the Affordable Care Act (ACA) to test payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care.

Acronym

QRUR

What It Stands For

Quality and Resource Use Report

Definition

The Quality and Resource Use Report (QRUR) provides information on a tax identification number’s (TIN) performance on all available quality and cost measures used to calculate the 2016 Value Modifier (VM). Annual QRURs will provide information on how the TIN's quality and cost performance affects their physicians’ Medicare physician fee schedule (PFS) payments.

See also: Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), CMS Enterprise Portal, Enterprise Identity Management (EIDM)

Acronym

PECOS

What It Stands For

Provider Enrollment, Chain and Ownership System

Definition

The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) is an online system that allows clinicians to electronically submit an initial Medicare enrollment application, update and manage enrollment information, track enrollment, manage reassignment of benefits, and withdraw from the Medicare Program. The Centers for Medicare & Medicaid Services (CMS) will use the information in PECOS to verify an eligible clinician's (EC’s) specialty and determine if the provider is considered newly enrolled for the purposes of the Merit-based Incentive Payment System (MIPS). CMS will also use the contact information provided in the EC’s PECOS record for communicating when MIPS performance feedback is available.

See also: Merit-based Incentive Payment System (MIPS)

Acronym

TCPi

What It Stands For

Transforming Clinical Practice Initiative

Definition

The Transforming Clinical Practice initiative (TCPi) is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over four years in sharing, adapting, and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act (ACA) to strengthen the quality of patient care and spend health care dollars more wisely.

Acronym

PTN

What It Stands For

Practice Transformation Network

Definition

Practice Transformation Networks (PTNs) are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation.

See also: Transforming Clinical Practice Initiative (TCPi)

Acronym

SAN

What It Stands For

Support and Alignment Network

Definition

Support and Alignment Networks (SANs) provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts.

Acronym

LAN

What It Stands For

Learning and Action Network

Definition

The goal of the Learning and Action Network (LAN) is to align private payers and the Centers for Medicare & Medicaid Services (CMS) to move payment from traditional fee-for-service (FFS) methods to FFS-linked quality and Alternative Payment Models (APMs). Specifically, the LAN goals are that in 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs. In 2018, at least 50% of U.S. health care payments are so linked. These payment reforms are expected to demonstrate better outcomes and lower costs for patients.

See also: Centers for Medicare & Medicaid (CMS), Alternative Payment Model (APM)

Acronym

PPACA/ACA

What It Stands For

Patient Protection and Affordable Care Act

Definition

Signed into law by President Barack Obama in 2010, the Patient Protection and Affordable Care Act (PPACA), or ACA, puts in place comprehensive health insurance reforms. Reforms include: expanded coverage, holding insurance companies accountable, lowering health care costs, and guaranteeing more choices in health care.

Acronym What It Stands For

Medicare Part A

Definition

Medicare Part A is an original (traditional) Medicare plan covering services such as hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Medicare Part A is managed by the Centers for Medicare & Medicaid Services (CMS).

Acronym What It Stands For

Medicare Part B

Definition

Medicare Part B an original (traditional) Medicare plan covering services such as lab tests, surgeries, office visits, and supplies that are considered medically necessary. Medicare Part B is managed by the Centers for Medicare & Medicaid Services (CMS). The Medicare Access and CHIP Reauthorization Act (MACRA) only applies to Medicare Part B patients and payments.

Acronym What It Stands For

Medicare Part C

Definition

Medicare Part C plans (also known as Medicare Advantage) are offered by private insurance plans to beneficiaries who are enrolled in original (traditional) Medicare. Medicare Advantage plans typically offer additional coverage such as vision, dental, hearing, and can include prescription drug coverage. Medicare Part C patients and payments are not affected by the Medicare Access and CHIP Reauthorization Act (MACRA).

Acronym What It Stands For Definition

Medicare Part D

Medicare Part D offers a prescription drug coverage option, which is available to original (traditional) Medicare plans.

Acronym: What It Stands For:

All-cause Hospital Readmissions

Definition:

All-cause hospital readmissions is the measure of readmission rate of beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission within 30 days of discharge. This measure is a claims-based outcome measure included in the quality performance category of the Merit-based Incentive Program (MIPS). CMS will calculate this measure for groups of 16 or more eligible clinicians with at least 200 cases. No data submission from clinicians is required.

See also: Merit-based Incentive Program (MIPS)

Acronym:

MSPB

What It Stands For:

Medicare Spending Per Beneficiary

Definition:

The Medicare spending per beneficiary (MSPB) is a measure of all Medicare Part A and B payments during an episode spanning three days prior to an index (inpatient prospective payment system [IPPS] hospital admission) through 30 days post discharge. This is a claims-based measure included in the cost performance category of the Merit-based Incentive Payment System (MIPS). Eligible clinicians will be scored on this measure if they meet the case minimum, which has been set at 35.

See also: Merit-based Incentive Program (MIPS), Medicare Part A, Medicare Part B

Acronym: What It Stands For:

Total Cost Per Capita

Definition:

Total cost per capita is a measure of overall efficiency of care provided to attributed beneficiaries. This is a claims-based measure included in the cost performance category in the Merit-based Incentive Payment System (MIPS). Eligible clinicians (ECs) will be scored on this measure if they meet the case minimum, which has been set at 20.

See also: Merit-based Incentive Program (MIPS)

Acronym:

CHIP

What It Stands For:

Children's Health Insurance Program

Definition:

The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Acronym: What It Stands For: Definition:

SGR

Sustainable Growth Rate

The sustainable growth rate (SGR) was the target set by the Centers for Medicare & Medicaid Services (CMS) to control the growth in aggregate of Medicare expenditures for physicians' services. It was repealed as part of of the Medicare Access and CHIP Reauthorization Act (MACRA) and is no longer used in the Medicare program.

See also: Medicare Access and CHIP Reauthorization Act (MACRA)

Acronym: What It Stands For:

Advanced Alternative Payment Model (AAPM) Entity

Definition:

An Advanced Alternative Payment Model (AAPM) entity is an entity that participates in an Alternative Payment Model (APM) that the Centers for Medicare & Medicaid Services (CMS) has determined to be an AAPM.

See also: Advanced Alternative Payment Model (AAPM)

Acronym: What It Stands For:

Alternative Payment Model (APM) Entity

Definition:

An Alternative Payment Model entity is an entity that participates in an Advanced Alternative Payment Model (AAPM) through a contract with a payer.

See also: Alternative Payment Model (APM)

Acronym: What It Stands For:

Attributed Beneficiary

Definition:

A beneficiary attributed to the Advanced Alternative Payment Model (AAPM) is on the latest available list of attributed beneficiaries during the Qualifying APM participant (QP) performance period. Beneficiary attribution is based on each APM's respective attribution rules.

See also: Advanced Alternative Payment Model (AAPM), Qualifying Alternative Payment Model (APM) Participant (QP), Partial Qualifying Alternative Payment Model (APM) Participant (Partial QP), Attribution-Eligible Beneficiary

Acronym: What It Stands For:

Attribution-eligible Beneficiary

Definition:

In order to be attributed to an Advanced Alternative Payment Model (AAPM) entity, a beneficiary must be one who: is not enrolled in Medicare Advantage or a Medicare cost plan; does not have Medicare as a secondary payer; is enrolled in both Medicare Parts A and B; is at least 18 years of age; is a U.S. resident; has a minimum of one claim for evaluation and management (E/M) services by an eligible clinician (EC) or group of eligible clinicians within an APM entity during the Qualifying APM participant (QP) performance period.

See also: Advanced Alternative Payment Model (AAPM), Qualifying Alternative Payment Model (APM) Participant (QP), Alternative Payment Model (APM)

Entity, Attributed Beneficiary

Acronym: What It Stands For:

Nominal Risk

Definition:

Contained in the Medicare Access and CHIP Reauthorization Act (MACRA) law, Advanced Alternative Payment Models (AAPMs) must assume nominal risk; or, risk of an amount that is lower than optimal, but substantial enough to drive performance.

See also: Advanced Alternative Payment Model (AAPM)

Acronym: What It Stands For:

High-priority Measure

Definition:

A high-priority measure is a quality measure within one of the following categories: outcome, appropriate use, patient safety, efficiency, patient experience, or care coordination.

Acronym: What It Stands For:

Episode-based Measure

Definition:

An episode-based measure includes Medicare Part A and B payments, and related to a triggering condition or procedure. Clinical and treatment episode-based measures are designed to evaluate resource utilization of specific procedures and conditions that are costly and prevalent in the Medicare population. Episode-based measures are included in the cost performance category of the Merit-based Incentive Payment System (MIPS). Eligible clinicians (ECs) will be scored on these measures if they meet the case minimum, which has been set at 20.

See also: Merit-based Incentive Program (MIPS), Medicare Part A, Medicare Part B

Acronym: What It Stands For:

New Medicare-enrolled Merit-based Incentive Payment System (MIPS) Eligible Clinician (EC)

Definition:

A new Medicare-enrolled Merit-based Incentive Payment System (MIPS) eligible clinician (EC) is a professional who first becomes a Medicare-enrolled eligible clinician within the Provider Enrollment, Chain, and Ownership System (PECOS) during the performance period and who has not previously submitted claims as a Medicare-enrolled EC either as an individual, an entity, or as part of a physician group or under a different billing number or tax identifier.

See also: Medicare Provider Enrollment, Chain, and Ownership System (PECOS)

Acronym: What It Stands For:

Non-patient Facing Merit-based Incentive Payment System (MIPS) Eligible Clinician (EC)

Definition:

A non-patient facing Merit-based Incentive Payment System (MIPS) eligible clinician (EC) is an EC or group that bills 100 or fewer patient-facing encounters during a performance period. A patient-facing encounter is coded as such when the clinician or group bills for services, such as general office visits, outpatient visits, and surgical procedure codes. Telehealth will also be considered patient-facing. The Centers for Medicare & Medicaid Services (CMS) has published a list of patient-facing encounter codes.

Acronym: What It Stands For:

Merit-based Incentive Payment System (MIPS) Performance Category

Definition:

As defined by Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) contains four performance categories: quality, cost, improvement activities, and advancing care information (meaningful use of EHR technology). An eligible clinician's (EC's) performance in each category will be weighted and contribute to the final score. The weights of the categories will change as the program progresses. Initially (performance year 2017 for payment in 2019), quality will be weighted at 60%, cost at 0%, improvement activities at 15%, and advancing care information at 25%.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS),Final Score, Improvement Activities (IA), Advancing Care Information (ACI), Eligible Clinician (EC), Performance Category Score

Acronym: What It Stands For:

Performance Category Score

Definition:

The performance category score is an assessment of each eligible clinician's (EC's) or group's performance on the applicable measures and activities for a performance category (quality, cost, advancing care information, improvement activities) in the Merit-based Incentive Payment System (MIPS). The performance category scores are used in the calculation of the final score.

See also: Eligible Clinician (EC), Final Score

Acronym:

What It Stands For:

Additional Performance Threshold

Definition:

Established at the final score level, the additional performance threshold is the additional level of performance at which an eligible clinician (EC) may achieve and receive an additional positive payment adjustment under the Merit-based Incentive Payment System (MIPS). CMS has set the additional performance threshold for exceptional performance at 70 for the 2017 performance period (2019 payment year).

See also: Final Score, Exceptional Performance

Acronym: What It Stands For:

Payment Adjustment Factor

Definition:

A payment adjustment factor is the percentage adjustment applied to a Merit-based Incentive Payment System (MIPS) eligible clinician's (EC’s) Medicare Part B payments, resulting in differential payments. The adjustment factor will be applied based on a linear sliding scale. An EC with a final score of zero will receive a neutral payment adjustment factor. This is also referred to as the MIPS adjustment factor.

Download a timeline for MACRA »

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Eligible Clinician (EC), Final Score

Acronym:

CF

What It Stands For:

Conversion Factor

Definition:

The conversion factor (CF) is the dollar amount updated on an annual basis used in determining payment rates for a particular service. The CF is multiplied by the relative value units (RVUs) of a service, resulting in the payment rate for the service.

See also: Resource-based Relative Value Scale (RBRVS)

Acronym:

PFS

What It Stands For:

Physician Fee Schedule

Definition:

The physician fee schedule (PFS) includes the list of Medicare-covered services and payment rates for those services. The list is updated annually.

Acronym:

What It Stands For:

Budget Neutrality

Definition:

Remaining budget neutral is a requirement of the Medicare Access and CHIP Reauthorization Act (MACRA) that ensures the amount of the positive payment adjustments do not exceed that of the negative payment adjustments.

Acronym:

HPSA

What It Stands For:

Health Professional Shortage Area

Definition:

Health professional shortage areas (HPSAs) are designated by the Human Resources and Services Administration (HRSA) as having shortages of primary care, dental, or mental health clinicians. HPSAs may be geographic, demographic, or institutional.

Acronym: What It Stands For:

Virtual Groups

Definition:

Virtual groups are an option allowing individual Merit-based Incentive Payment System (MIPS) eligible clinicians (ECs) or groups with 10 or fewer eligible clinicians to elect to report as a group in MIPS. The virtual group option is not available during the 2017 performance period.

See also: Merit-based Incentive Program (MIPS), Eligible Clinician (EC)

Acronym:

CAHPS

What It Stands For:

Consumer Assessment of Healthcare Providers and Systems

Definition:

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a survey tool used to ask patients to report their experiences with the health care system. The survey can be administered through a Centers for Medicare & Medicaid Services (CMS)-approved survey vendor.

Acronym:

PTAC

What It Stands For:

Physician-focused Payment Model Technical Advisory Committee

Definition:

The Physician-focused Payment Model Technical Advisory Committee (PTAC) was established under the Medicare Access and Chip Reauthorization Act (MACRA) and will provide comments and recommendations to the Secretary of Health and Human Services (HHS) on physician payment models, such as alternative payment models.

See also: Physician-focused Payment Model (PFPM), Medicare Access and CHIP Reauthorization Act (MACRA), Alternative Payment Model (APM), Health and Human Services (HHS)

Acronym:

PFPM

What It Stands For:

Physician-focused Payment Model

Definition:

A physician-focused payment model (PFPM) is an alternative payment model (APM) where Medicare is a payer, and includes physician group practices or individual physicians as Alternative Payment Model (APM) entities and targets the quality and costs of physician services. The Physician-focused Payment Model Technical Advisory Committee will review proposed PFPMs.

See also: Physician-focused Payment Model Technical Advisory Committee (PTAC), Alternative Payment Model (APM)

Acronym:

EIDM

What It Stands For:

Enterprise Identity Management

Definition:

Enterprise Identity Management (EIDM) is a system used by the Centers for Medicare & Medicaid Services (CMS) for identity verification, access management, password reset, etc. An EIDM account is required to login into the CMS Enterprise Portal.

See also: CMS Enterprise Portal

Acronym:

What It Stands For:

CMS Enterprise Portal

Definition:

The CMS Enterprise Portal is an online portal maintained by the Centers for Medicare & Medicaid Services (CMS) to provide access to various CMS systems and databases. An Enterprise Identity Management (EIDM) user account is required to login to the portal. This portal allows users to access their Quality and Resource Use Reports (QRUR.

See also: Enterprise Identity Management (EIDM), Centers for Medicare & Medicaid (CMS), Quality and Resource Use Report (QRUR), Physician Quality Reporting System (PQRS)

Acronym:

What It Stands For:

URAC

Definition:

URAC is an independent organization offering patient-centered medical home (PCMH) accreditation. Practices receiving PCMH recognition from URAC will automatically receive full credit in the improvement activities (IA) performance category.

See also: Patient-centered Medical Home (PCMH), Improvement Activities (IA)

Acronym:

TJC

What It Stands For:

The Joint Commission

Definition:

The Joint Commission (TJC) is an independent, non-profit organization offering patient-centered medical home (PCMH) accreditation. Practices receiving PCMH recognition from TJC will automatically receive full credit in the improvement activities (IA) performance category.

See also: Patient-centered Medical Home (PCMH), Improvement Activities (IA)

Acronym:

NCQA

What It Stands For:

National Committee for Quality Assurance

Definition:

The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization offering patient-centered medical home (PCMH) recognition. Practices receiving PCMH recognition from the NCQA will automatically receive full credit in the improvement activities (IA) performance category.

See also: Patient-centered Medical Home (PCMH), Improvement Activities (IA)

Acronym:

AAAHC

What It Stands For:

Accreditation Association for Ambulatory Health Care

Definition:

The Accreditation Association for Ambulatory Health Care (AAAHC) is a private, non-profit organization offering patient-centered medical home (PCMH) recognition. Practices receiving PCMH recognition from the NCQA will automatically receive full credit in the improvement activities (IA) performance category.

See also: Patient-centered Medical Home (PCMH), Improvement Activities (IA)

1Source - AMERICAN ACADEMY OF FAMILY PHYSICIANS – Published on website-fp@aafp.org