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Not All APMs Are Equal

Not All APMs Are Equal

Some APMs do not exempt clinicians from MIPS.

In this transition year of the Quality Payment Program, practices have the option to participate in an alternate payment model (APM). There are advantages to doing so, but you must do your homework.
In 2017, some APMs will not meet statutory requirements to be categorized as advanced APMs. Clinicians who are eligible to participate in the Merit-based Incentive Payment System (MIPS) and who participate in such APMs are actually in MIPS APMs. It’s important to know your clinicians’ participation level to ensure proper reporting to and payment from the Centers for Medicare & Medicaid Services (CMS).

Identifying MIPS APMs

MIPS APMs meet three criteria:

  1. APM entities participate in the APM under an agreement with CMS, or by law or regulation;
  2. APM entities include at least one MIPS eligible clinician on a participation list; and
  3. The APM bases payment incentives on performance (either at the APM entity level or eligible clinician level) on cost and quality measures.

MIPS APMs in 2017:

  • Medicare Shared Savings Program Accountable Care Organizations (ACOs) – Tracks 1, 2, and 3 (tracks 2-3 are advanced APMs)
  • Next Generation ACO Model (advanced APM)
  • Comprehensive End-stage Renal Disease (ESRD) Care (CEC) Model (large dialysis organization (LDO) arrangement) (advanced APM)
  • Comprehensive ESRD Care (CEC) Model (non-LDO arrangement one-sided risk arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement) (advanced APM)
  • Oncology Care Model (OCM) (one-sided risk arrangement)
  • Oncology Care Model (OCM) (two-sided risk arrangement) (advanced APM)
  • Comprehensive Primary Care Plus (CPC+) Model (advanced APM)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-payer ACO Model) (advanced APM)

If a MIPS eligible clinician does not meet the threshold of having sufficient payments or patients through an advanced APM to become a qualifying participant (QP), the eligible clinician is scored under MIPS and the APM scoring standard. These scores are aggregated to the APM entity level, and all eligible clinicians in the APM entity receive the same MIPS final score.

APM Scoring Standard

CMS will review MIPS APM participation lists on March 31, June 30, and Aug. 31 (instead of the proposed one-time date of Dec. 31). To be considered part of a MIPS APM entity for the APM scoring standard, an eligible clinician must be on an APM participation list on at least one of those dates during the MIPS performance year. Otherwise the eligible clinician or group must report MIPS data to Medicare through standard means by March 31 of the following year to avoid a negative payment adjustment.
Important: If the applicable data submission requirements include full-year reporting, the MIPS individual or group must report for the full year to receive credit.

Score Big

The performance categories — Quality, Cost, Improvement Activities, and Advancing Care Information — are the same for MIPS APMs as those for MIPS reporters, but the requirements are different. For example, for 2017, clinicians participating in a MIPS APM will receive full credit for improvement activities.
The weights applied to the improvement activities performance category under the APM scoring standard in the 2017 performance year are:

  • The Shared Savings Program and the Next Generation ACO Model improvement activities performance category weight is 20 percent.
  • MIPS APMs other than the Shared Savings Program and the Next Generation ACO Model (including the CPC+ Model, the CEC Model, and the OCM) improvement activities performance category weight is 25 percent.

Watch Your Back

Your MIPS APM entity doesn’t submit quality data on your behalf, it’s your responsibility to do so through MIPS reporting. Failing to report data in this category will earn you a big, fat zero and a negative payment adjustment in 2019.

Eligible Clinician or QP?

Medicare Part B clinicians billing more than $30,000 a year and providing care for more than 100 Medicare patients a year are eligible to participate in the Merit-based Incentive Payment System (MIPS). To be a qualifying participant (QP) of an advanced alternate payment model (APM), exempt from MIPS, clinicians must receive 25 percent of their Medicare payments or see 20 percent of their Medicare patients through an advanced APM (exceptions exist). Note that QPs are not only excluded from MIPS, but also receive a 5 percent lump sum bonus starting in 2019 and a higher Physician Fee Schedule update starting in 2026.

Scores for Improvement Activities in MIPS APMs in the 2017 Performance Period, Dec. 29, 2016, https://qpp.cms.gov/docs/QPP_APMs_and_Improvement_Activities.pdf

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Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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