- June 4, 2025
- Posted by: Josh Knoll
- Category: Physician Billing
Medicare payment structure for physicians has gone through a lot of changes over the years. One of the biggest paradigm shifts came with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which replaced the old system of rewarding physicians based on the number of services. MACRA always appreciates the value of better patient outcomes that you bring to the table. But if doctors provided more services, future payments would be reduced. This caused a good deal of confusion and stress in the initial days. Doctors didn’t know if their payments would drop each year, and Congress had to step in often to stop big pay cuts. This sudden change made many physicians feel frustrated by making their financial planning difficult. For physician billing services, it caused major problems too.
To ensure a perfect physician billing service, you must understand what MACRA is, how it changed reimbursement, and what it means for your overall billing game.
What Is MACRA?
Congress passed a new payment path called MACRA in 2015 which focused on quality, value, and performance instead of paying physicians based on the number of provided services. It underscored a significant shift towards value-based care.
MACRA created two new paths for payment:
- MIPS (Merit-based Incentive Payment System)
- APMs (Advanced Alternative Payment Models)
These models reward physicians for doing a good job—not just for doing more work. And that has changed everything about physician billing solutions.
To understand MACRA better, you should understand what MIPS and APMs are.
Understanding MIPS and APMs:
Most physicians follow the MIPS path under MACRA. In MIPS, Medicare payments depend on a score. This score comes from four areas — quality of care, cost of care, improvement activities, and sharing of health data electronically. Each area gives points, and the total score decides if a doctor gets more, less, or the exact payment. Many physicians also follow advanced APM paths. These are special value-based payment models like ACOs, Patient-Centered Medical Homes, and Bundled Payments. Doctors in APMs don’t follow MIPS. Instead, they take on financial risk. If they give good, cost-effective care, they earn more money.
It is important to understand how MACRA changed Medicare payments in the context of physician billing services.
How MACRA Changed Medicare Payments in Physician Billing Services:
1. Prioritizing Value-Based Payment
Medicare paid physicians based on the volume of care before 2015. A physician could earn more for performing more tests and procedures before 2015 but now, they are paid for better patient outcomes under MIPS and APMs paths defined by MACRA. Now, two physicians who do the same work could be paid very differently as the payment depends on the quality of care and patient outcomes. A good physician billing solution helps track these outcomes and submit data correctly.
2. Incentives and Penalties
With MIPS, doctors can earn bonuses for good performance. However, poor performance can also lead to penalties. This creates financial risk, especially for small practices.
The role of a physician billing service now includes more than just submitting claims. It also involves strategic support to improve your MIPS score.
3. Increased Reporting Requirements
MACRA added new layers of data reporting. You need to report on clinical quality measures, cost benchmarks, patient engagement, and more. This can be overwhelming for a busy practice.
MACRA has been hard for small practices. Many don’t have enough staff or tools to handle the new reporting rules, thus causing them to face the following challenges:
The Major MACRA Roadblocks that Physicians Still Struggle With:
Even now, many practices struggle with MACRA rules. Common issues include:
- Not understanding MIPS scoring
- Missing reporting deadlines
- Using outdated billing systems
- Coding errors that reduce performance scores
This is why opting for an outsourced physician billing solution can help. A good billing partner tracks MIPS scores, uses the right codes, meets reporting deadlines, and alerts you about penalties or bonus chances. This support helps protect your revenue and boosts your Medicare payments.
Let’s go through a real-life example of a MACRA–expert physician billing company like SunKnowledge Inc. has helped a family physician.
Real-World Example: How MACRA Changed a Practice
Let’s look at a simple case.
Dr. Smith is a family physician with a thriving practice. Before MACRA, her practice earned a steady income from Medicare by seeing more patients. However, once MACRA started, she faced new reporting rules and payment changes.
She failed to report her MIPS data correctly in 2018 and received a 5% payment cut.
In 2020, she subscribed to SunKnowledge’s physician billing service with MACRA expertise. They helped her:
- Track quality measures in real-time
- Submit accurate reports
- Avoid costly errors
- Improve patient follow-up
By 2021, she earned a 7% positive adjustment.
This is how the right physician billing solution can turn challenges into opportunities. If you are considering physician billing outsourcing, look no further than SunKnowledge Inc.
SunKnowledge: The Perfect Physician Billing Outsourcing Partner
We, at SunKnowledge, have been the preferred RCM partner for top physician practices across the nation. Regardless of the size of your practice, our physician billing solutions are fully equipped to eliminate all your billing hassles. We make it easy for you to focus on patient care while we handle your Medicare billing under MACRA rules. From tracking MIPS scores to meeting reporting deadlines, we do it all.
We have been working as a complete operational extension for providers across the U.S., bringing our deep domain knowledge from years of working with different payers in the nation. This gives us a clear understanding of how healthcare payments work. The best part of hiring us is that each of our billing experts can efficiently work on all the popular billing platforms, thus ensuring zero training headaches from your side.
Let SunKnowledge help you stay compliant with MACRA, improve your collections, and grow your practice with confidence.