Medicare MACRA in 2018 For Chiropractors: 8 Things You Need to Know

This month (November 2017), the Centers for Medicare & Medicaid Services (CMS) released its final rule related to the Medicare Quality Payment Program in 2018. Many may recognize the quality program under its abbreviation known as MACRA which shortens its real mouthful of a name which is: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Cutting straight to the bottom line: there are 8 big things you need to know about Medicare MACRA in 2018 for chiropractors which can affect your Medicare payments in 2020. This means doctors of chiropractic have a little time to get ready and make a decision of how you will or will not move forward with MACRA in 2018. To help you make that decision, here are the top things you need to know about MACRA in 2018:

1. Expanded Exemptions

Many chiropractors were exempt from MACRA penalties in its first year and many will continue to fall under the exemption categories in the coming year as well. For 2018, chiropractors with $90,000 or less in Medicare Part B allowed charges will be exempt. Additionally, chiropractors with 200 or fewer unique Medicare patients will be exempt from participation in the quality metric reporting.

There are a few important things to remember with regards to these exemptions. First, you do not have to submit anything to be exempt; your numbers must be below threshold amounts listed above.  Secondly, the dollar amount or patient amount is an either/or scenario.  In other words, if your practice had less than $90,000 in allowed charges from Medicare, you are exempt.  OR, if your practice had fewer than 200 unique Medicare patients (note: this is not the same as 200 Medicare patient visits; this means fewer than 200 different patients for whom you billed Medicare for at least one visit)

2. Cost Category Added

A new addition to Medicare MACRA in 2018 for chiropractors will be the cost category, which will be factored in at 10% of your final score. Medicare plans to calculate cost by looking at the amount of spending per beneficiary (i.e. per patient). Since chiropractors are only reimbursed for one service, what this basically means for us is that chiropractors who see patients more frequently will have a higher average spending amount per patient, than those who see patients less frequently. And, of course, Medicare’s MACRA formula will look to reward those with the lowest spending.

3. New Clinical Improvement Activities

For your learning pleasure, Medicare has added new clinical improvement activities to report in 2018. As some of these aren’t particularly relevant or easy to adopt for chiropractors, what this basically means is that you will have to do some MACRA training to see if these activities would be among those that your practice would be likely to report or if you will keep the game the same in 2018 as you did this year.

4. Increased Performance Threshold

Unfortunately, but not surprisingly, Medicare bumped up the scoring system performance threshold for 2018, thus making it a bit harder to avoid a penalty. Translation: Medicare MACRA in 2018 for chiropractors will require DC’s to report more in 2018 to avoid a penalty than you did in 2017.

5. Increased Penalty or Bonus

Accordingly, Medicare MACRA in 2018 for chiropractors also raised the penalty for docs who do not meet the exemption criteria AND who do not choose to report. If you fail to meet the MACRA requirements in 2018, then you will receive a negative payment adjustment of 5% in 2020 (up 1% from last year’s penalty). Similarly, those who do successfully report in 2018 will be eligible to receive up to a 5% increase in reimbursement in 2020.

6. Small Practice Bonus

In 2018, small practices (which will be most chiropractic practices) will get five bonus points on their MIPS final scores – just for being small. How small? Medicare defines “small physician practices” as those with 15 or fewer eligible clinicians. The bonus is awarded as long as the eligible physician (or group) submits data for at least one performance category.

7. Hardship Criteria Still in Place

CMS also announced that it will continue to allow required physicians to apply for hardship exemptions in the advancing care information performance category regarding their EHR systems. This can include insufficient internet connectivity and lack of control over availability of certified EHRs.  Note: this is not the same as meeting the universal exemption criteria mentioned above.  The hardship exemption is strictly for those who are required to participate (not exempt by rule), but because of certain circumstantial problems, they were not able to complete their participation requirements.  To be eligible for a hardship exemption, you must apply after the calendar year is over stating why you did not meet the criteria, even though you were required.

8. New “Virtual Groups”

Finally, in the 2018, CMS will permit the creation of “virtual groups” for solo practitioners and groups of 10 or fewer eligible clinicians. These professionals can partner with at least one other group to report MIPS quality metrics, regardless of location or specialty.  With the addition of the Small Physician Bonus (as mentioned above in #6), the advantages of forming a virtual group certainly won’t be a benefit for all chiropractors, but…Medicare has developed a Virtual Groups toolkit to assist eligible physicians in understanding the ins and outs of this new structure.

And those are the highlights of the big changes in Medicare MACRA in 2018 for chiropractors!


Your participation in MACRA is basically a big math exercise, in my humble opinion.  In other words, deciding to fulfill the requirements of MACRA should be made by you, on an individual basis, based on your clinic’s stats and projections and taking into account the ramifications of a penalty as well as the work involved to achieve any penalty avoidance or bonus pay.

Based on your current Medicare revenues, some of you can make the decision to adopt or avoid MACRA procedures in 2018 right now.  But many chiropractors will need to look at their 2017 stats to reach a meaningful decision for what to do in 2018.

Here’s good news:

Deciding early in 2018 will give you the greatest flexibility in looking to achieve positive reimbursement bonuses in the future AND it will give you the best chance to avoid penalties as well.  So don’t procrastinate and make your decision of which route to take early on.

Need help deciding what’s best for you in 2018? Our FREE WEBINAR is designed to assist you in Making the MACRA Decision in 2018!  Join us as we explain the details of what you will need to to do participate or avoid penalties and let us help you “do the math” to get your chiropractic practice started on the right track for a great 2018.   

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