Social Security Act §1833

(2)Definitions.In this subsection.(A)General surgeon.In this subsection,the term general surgeon means a physician (as describedin section 1861(r)(1)) who hasdesignated CMS specialty code 02 General Surgery as their primaryspecialty code in the physicians enrollment under section 1866(j).(B)Major surgical procedures.The term major surgical procedures means physicians serviceswhich are surgical procedures for which a 10-day or 90-day globalperiod is used for payment under the fee schedule under section 1848(b).(3)Coordinationwith others.The amount of the additionalpayment for a service under this subsection and subsection (m) shall be determined withoutregard to any additional payment for the service under subsection(m) and this subsection, respectively. The amount of the additionalpayment for a service under this subsection and subsection (z) shallbe determined without regard to any additional payment for the serviceunder subsection (z) and this subsection, respectively.[139](4)Application.The provisions of paragraph (2) and (4) of subsection (m) shallapply to the determination of additional payments under this subsectionin the same manner as such provisions apply to the determination ofadditional payments under subsection (m).(z)IncentivePayments for Participation in Eligible Alternative Payment Models.[140](1)Paymentincentive.(A)In general.In the case of coveredprofessional services furnished by an eligible professional duringa year that is in the period beginning with 2019 and ending with 2024and for which the professional is a qualifying APM participant withrespect to such year, in addition to the amount of payment that wouldotherwise be made for such covered professional services under thispart for such year, there also shall be paid to such professionalan amount equal to 5 percent of the estimated aggregate payment amountsfor such covered professional services under this part for the precedingyear. For purposes of the previous sentence, the payment amount forthe preceding year may be an estimation for the full preceding yearbased on a period of such preceding year that is less than the fullyear. The Secretary shall establish policies to implement this subparagraphin cases in which payment for covered professional services furnishedby a qualifying APM participant in an alternative payment model(i)is made to aneligible alternative payment entity rather than directly to the qualifyingAPM participant; or(ii)is made on abasis other than a fee- for-service basis (such as payment on a capitatedbasis).(B)Form of payment.Payments under thissubsection shall be made in a lump sum, on an annual basis, as soonas practicable.(C)Treatment of payment incentive.Paymentsunder this subsection shall not be taken into account for purposesof determining actual expenditures under an alternative payment modeland for purposes of determining or rebasing any benchmarks used underthe alternative payment model.(D)Coordination.The amount of the additionalpayment under this subsection or subsection (m) shall be determinedwithout regard to any additional payment under subsection (m) andthis subsection, respectively. The amount of the additional paymentunder this subsection or subsection (x) shall be determined withoutregard to any additional payment under subsection (x) and this subsection,respectively. The amount of the additional payment under this subsectionor subsection (y) shall be determined without regard to any additionalpayment under subsection (y) and this subsection, respectively.(2)Qualifyingapm participant.For purposes of thissubsection, the term qualifying APM participant meansthe following:(A)2019 and 2020.With respect to 2019and 2020, an eligible professional for whom the Secretary determinesthat at least 25 percent of payments under this part for covered professionalservices furnished by such professional during the most recent periodfor which data are available (which may be less than a year) wereattributable to such services furnished under this part through aneligible alternative payment entity.(B)2021 and 2022.With respect to 2021and 2022, an eligible professional described in either of the followingclauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 50 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 50 percentof the sum of(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(C)Beginning in 2023.With respect to2023 and each subsequent year, an eligible professional describedin either of the following clauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 75 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 75 percentof the sum of(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(D)Use of patient approach.The Secretarymay base the determination of whether an eligible professional isa qualifying APM participant under this subsection and the determinationof whether an eligible professional is a partial qualifying APM participantunder section 1848(q)(1)(C)(iii) by using counts of patients in lieuof using payments and using the same or similar percentage criteria(as specified in this subsection and such section, respectively),as the Secretary determines appropriate.(3)Additionaldefinitions.In this subsection:(A)Covered professional services.Theterm covered professional services has the meaninggiven that term in section 1848(k)(3)(A).(B)Eligible professional.The term eligible professional has the meaning given that term insection 1848(k)(3)(B) and includes a group that includes such professionals.(C)Alternative payment model (apm).Theterm alternative payment model means, other than forpurposes of subparagraphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph(2), any of the following:(i)A model undersection 1115A (other than a health care innovation award).(ii)The shared savingsprogram under section 1899.(iii)A demonstrationunder section 1866C.(iv)A demonstrationrequired by Federal law.(D)Eligible alternative payment entity.The term eligible alternative payment entity means,with respect to a year, an entity that(i)participates inan alternative payment model that(I)requiresparticipants in such model to use certified EHR technology (as definedin subsection (o)(4)); and(II)providesfor payment for covered professional services based on quality measurescomparable to measures under the performance category described insection 1848(q)(2)(B)(i); and(ii)(I)bears financialrisk for monetary losses under such alternative payment model thatare in excess of a nominal amount; or(II)is a medicalhome expanded under section 1115A(c).(4)Limitation.There shall be no administrative or judicial review under section1869, 1878, or otherwise, of the following:(A)The determinationthat an eligible professional is a qualifying APM participant underparagraph (2) and the determination that an entity is an eligiblealternative payment entity under paragraph (3)(D).(B)The determinationof the amount of the 5 percent payment incentive under paragraph (1)(A),including any estimation as part of such determination.[141](z)MedicalReview of Spinal Subluxation Services.[142](1)In general.The Secretary shall implement a process for the medical review(as described in paragraph (2)) of treatment by a chiropractor describedin section 1861(r)(5) by meansof manual manipulation of the spine to correct a subluxation (as describedin such section) of an individual who is enrolled under this partand apply such process to such services furnished on or after January1, 2017, focusing on services such as(A)servicesfurnished by a such a chiropractor whose pattern of billing is aberrantcompared to peers; and(B)servicesfurnished by such a chiropractor who, in a prior period, has a servicesdenial percentage in the 85th percentile or greater, taking into considerationthe extent that service denials are overturned on appeal.(2)Medicalreview.(A)Prior authorization medical review.(i)