Source: http://psoservicesllc.com/FAQ
Timestamp: 2020-02-29 07:52:18
Document Index: 752136825

Matched Legal Cases: ['§414', '§414', '§414', '§414', '§414', '§414', '§414', '§ 414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§1395', '§495', '§1315', '§414', '§414', '§414', '§1395', '§414', '§414', '§414', '§414', '§414', '§414', '§414', '§414']

PSO Services > FAQ
What is MACRA and what does it do?
When did the Quality Payment Program start?
Physicians could have started collecting performance data on January 1, 2017. Physicians who were not quite ready on January 1 could have begun collecting data anytime between January 1 and October 2, 2017. Regardless of when you chose to begin collecting data, physicians must have submitted their data by March 31, 2018. The first payment adjustments based on the 2017 reporting performance period will go into effect in 2019.
The MIPS performance years begin on January 1 and end on December 31 each year. Data for the prior calendar year must be submitted by March 31 of the following calendar year to avoid a payment reduction in the next year.
How will the physician know if they meet the low-volume threshold to be exempted from MIPS?
CMS will calculate whether a Medicare clinician meets the low-volume threshold. For the 2017 reporting year, CMS estimated that over 30 percent of eligible clinicians will be exempt from MIPS because of the low-volume threshold. Under the 2018 thresholds, CMS estimates that an additional 123,000 clinicians will be exempt. Physicians can use their National Provider Identifier (NPI) to look up whether they meet the low-volume threshold and are exempt from MIPS with the CMS MIPS Participation Status online portal found on the CMS Quality Payment Program website at https://qpp.cms.gov/participation-lookup.
Will physicians who provide services at federally qualified health centers (FQHCs) and rural health clinics (RHCs) be subject to payment adjustments under MIPS?
This will depend on how items and services by a MIPS eligible clinician are paid under Part B in a FQHC or RHC. If services rendered by an eligible clinician are billed and paid under the RHC or FQHC’s all-inclusive payment methodology, the MIPS adjustment would not apply to the facility payment to the FQHC or RHC. Such clinicians, however, may voluntarily report on applicable measures and activities. However, if a MIPS eligible clinician furnishes services in a FQHC or RHC and bills for those services under the Medicare Physician Fee Schedule, the MIPS adjustment will apply to payments made for those items and services. (81 Fed.Reg. at 77051.).
Are physicians practicing in a critical access hospital (CAH) eligible to participate in MIPS?
Yes. For MIPS eligible physicians practicing in Method I and II CAHs and who have not assigned their billing rights to the CAH, the MIPS payment adjustment would apply to payments made for items and services that are Medicare Part B allowed charged billed by the physicians. However, the payment adjustment would not apply to the facility payment to the CAH itself. For MIPS eligible physicians practicing in Method II CAHs who have assigned their billing rights to the CAH, CMS applies the payment adjustment to the Method II CAH payments. See MIPS Participation Fact Sheet on the CMS Quality Payment Program website at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPS-Participation-Fact-Sheet-2017.pdf.
How are MIPS eligible clinicians assessed?
MIPS eligible clinicians will be subject to payment adjustments to Medicare reimbursements based on an annual assessment in four performance categories:
Quality. This category replaces PQRS and assesses quality measures included in the MIPS final list published by November 1 of each year. This includes national specialty society measure sets.
Cost. This category replaces the VM and calculates performance based on physician spending. CMS calculates cost measure performance based on Medicare claims. Physicians do not need to report for this category.
Improvement Activities. This is a new category that support “broad aims within healthcare delivery, including care coordination, beneficiary engagement, population management, and health equity.” It assesses how a physician improves their care processes, enhances patient engagement in care, and increases access to care. The inventory of activities allows physicians to choose the activities most appropriate to their practices and may largely be activities that physicians already perform.
Advancing Care Information. This category replaces the EHR Incentive Program and the meaningful use criteria and focuses on “the secure exchange of health information and the use of certified electronic health record technology (CEHRT) to support patient engagement and improved healthcare quality.” Physicians can choose measures that advance the productive use of health information by sharing information with other clinicians or patients in a comprehensive manner.
(81 Fed.Reg. at 77015.) Clinicians will receive a composite score derived from the measures and activities they report. CMS will then use that score to compare to overall performance thresholds and make positive, neutral, or negative payment adjustments.
How is the MIPS performance score calculated?
Each performance category is weighted across the four performance categories, which are adjusted over the first three years of the program as follows:
2017 2018 2019 and beyond
(42 C.F.R. §§414.1330, 414.1350, 414.1355, 414.1375, 414.1380.) Note that these are default weights, and CMS can adjust it in certain circumstances.
For the 2017 transition reporting period, Quality makes up 60 percent, Advancing Care Information makes up 25 percent, Improvement Activities makes up 15 percent, while Cost is not to be factored into the composite score that determines the payment adjustment in 2019.
For the 2018 reporting period, Quality will make up 50 percent, Advancing Care Information will make up 25 percent, Improvement Activities make up 15 percent, and Cost will make up 10 percent of the composite score that will determine the payment adjustment in 2020.
Measures and activities are scored as follows in the four performance categories:
Quality. Scored between 1 and 10 points and measured against benchmarks. Bonus points are available for submitting specific types of measures and submitting measures using end-to-end electronic reporting. Beginning in the 2018 performance reporting year, improvement scoring is available.
Cost. Scored between 1 and 10 points and measured against benchmarks. Beginning in the 2018 performance reporting year, improvement scoring is available.
Improvement Activities. Each improvement activity is worth a certain number of points which are summed and scored against the total maximum score of 40 points.
Advancing Care Information. Sum of the base score, performance score, and bonus score. See Question 10.
In addition, MIPS eligible clinicians, groups, virtual groups, or APM entities that submit data on at least 1 performance category during the 2018 performance period can earn up to 5 bonus points for the treatment of complex patients or 5 bonus points for practicing in a small practice (defined as 15 or fewer eligible clinicians). (42 C.F.R. §414.1380.)
The final composite score of 0 to 100 points for a performance period for MIPS payment year is determined by the sum of each performance category score multiplied by the performance category weight plus the any applicable bonus points for small practices and the treatment of complex patients. (Id.)
What do physicians need to do to report under MIPS?
The following provides a brief description of each performance category and what must generally be reported to CMS by a MIPS eligible clinician. Note that the reporting requirements vary depending on whether a clinician is reporting as an individual or as a group, how the data is submitted, where the clinician is located, and whether the clinician is in an APM.
Quality. MIPS eligible clinicians must submit data on six measures, including at least one outcome measure, for the full calendar year in the 2018 performance year. Clinicians can select measures individually or report from a specialty-specific measure set. (42 C.F.R. §§414.1320 and 414.1335; CMS Quality Payment Program website at https://qpp.cms.gov/mips/quality-measures.)
Cost. CMS uses administrative claims data to assess performance and there is no requirement to submit or report any data. Note that while CMS will calculate the Cost category in 2017 transition period, it will not count towards the composite score and thus will not be used to determine the payment adjustment in 2019. Cost will comprise 10 percent of the composite score in the 2018 performance year to determine the payment adjustment in 2020. (42 C.F.R. §414.1350.)
Improvement Activities. MIPS eligible clinicians must attest to four medium weighted or two high-weighted activities for a minimum of a continuous 90-day period. This requirement is further reduced to two medium-weighted or one high-weighted activity for small practices (fewer than 15 participants), rural practices, practices located in geographic health professional shortage areas, and non-patient facing MIPS eligible clinicians. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model automatically earn full credit in this category. Participants in a non-qualifying MIPS APMs will receive half of the total improvement activities score automatically and may report additional activities to receive full credit. (42 C.F.R. §§414.1320 and 414.1365; CMS Quality Payment Program website at https://qpp.cms.gov/mips/improvement-activities.)
Advancing Care Information. MIPS eligible clinicians must attest or report in the following five required measures: 1) security risk analysis; 2) electronic prescribing; 3) provide patient access; 4) send a summary of care; and 5) request/accept summary of care. (Note for the 2017 transition period, the required measures to send, request, or accept a summary of care is combined to a broader requirement for health information exchange.) These required measures will first determine a base score that is one of three scores that make up the total Advancing Care Information score. Second, physicians can then choose to submit up to nine measures for an additional performance score. Third, CMS will also award a bonus score for the use of CEHRT to complete certain activities in the improvement activities performance category, the use of 2015 Edition CEHRT, and for reporting to public health or clinical data registries. (42 C.F.R. §§414.1375 and 414.1380; CMS Quality Payment Program website at https://qpp.cms.gov/mips/advancing-care-information.)
CMS will also reweigh the Advancing Care Information performance category to 0 percent from 25 percent and reallocate that 25 percent to the Quality performance category for “special status” MIPS eligible clinicians including 1) hospital based clinicians who deliver 75 percent or more of their Medicare Part B services through a hospital; 2) ambulatory surgical center based clinicians; 3) physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists; and 4) non-patient facing clinicians. These clinicians will be automatically exempted from the Advancing Care Information category and do not need to submit a hardship exception application.
In addition, other MIPS eligible clinicians may apply to obtain an exemption from the Advancing Care Information category for “significant hardship.” Hardships can include insufficient Internet connectivity, extreme and uncontrollable circumstances, lack of control over the availability of CEHRT, clinicians in small practices, or whose EHR was decertified. If CMS grants the exemption, the Advancing Care Information score will be reweighted to 0 percent. MIPS eligible clinicians must submit a Quality Payment Program Hardship Exception application by December 31, 2018.
For more information on the Advancing Care Information Performance Category including a detailed explanation on how the Advancing Care Information score is calculated and a full list of Advancing Care Information measures, see CMS’ Advancing Care Information Performance Category Fact Sheet, available at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html.
For more information on the required measures and activities under each of the MIPS performance categories, including an online tool to browse the different MIPS measures and activities, visit the CMS Quality Payment Program website at https://qpp.cms.gov or the CMS 2018 Resources website at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html.
Can MIPS eligible physicians report as a group?
Yes. Physicians can participate in MIPS and report as individuals or as a group. If a physician submits data as an individual, meaning a single NPI that is tied to a single Tax Identification Number (TIN), their payment adjustment will be based on their performance alone. Physicians can also submit data to CMS as a group. The group will get one payment adjustment based on the group’s performance across all four MIPS performance categories. (42 C.F.R. §414.1310.) A group means “a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their individual NPI, who have reassigned their billing rights to the [group] TIN.” (42 C.F.R. § 414.1305.) For more information on group reporting, visit the CMS Quality Payment Performance website at https://qpp.cms.gov/learn/about-group-registration​.
A virtual group is a combination of two or more TINs assigned to one or more solo practitioners, or to one or more groups consisting of ten (10) or fewer clinicians (including at least one (1) MIPS eligible clinician), or both, that elect to form a virtual group for a performance period for a year. (42 C.F.R. §414.1305.)
For solo practitioners, they must be a MIPS eligible clinician who exceeds the low-volume threshold. Such solo practitioners may not be a newly Medicare-enrolled MIPS eligible clinician, a Qualifying APM Participant (QP), or a Partial QP choosing not to participate in MIPS. For groups, they must have: 1) ten (10) or fewer clinicians; 2) at least one (1) MIPS eligible clinician; and 3) exceed the low-volume threshold at the group level. (42 C.F.R. §§414.1315(a), 414.1310(b) and (c); see also CMS’ Virtual Group Participation Overview Fact Sheet, available at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html.)
What are the requirements for a virtual group?
Solo practitioners or groups of ten (10) or fewer eligible clinicians must submit an election to participate in MIPS as a virtual group by December 31 of the calendar year prior to the start of the applicable performance period. (42 C.F.R. §414.1315.) Elections cannot be changed once the performance period begins. Virtual group participants may elect to be in no more than one virtual group for a performance period and, in the case of a group, the election applies to all MIPS eligible clinicians in the group. Each MIPS eligible clinician in the virtual group will receive a MIPS payment adjustment based on the virtual group's combined performance assessment, unless the MIPS eligible clinicians are also in a MIPS APM in which case the MIPS payment adjustment for these eligible clinicians is based solely on their APM Entity score. (42 C.F.R. §§414.1305 and 414.1315.) For more information on the virtual group election process, see Virtual Groups Election Process Fact Sheet available as part of the 2018 Virtual Group Toolkit at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html.)
Does the arrangement require a virtual group agreement?
Yes. The virtual group arrangement must be set forth in a formal written agreement between each solo practitioner and group that composes a virtual group before an election is made. The virtual group agreement must:
Identify the parties to the agreement by name, TIN, and NPI;
Be executed on behalf of each party by an individual who is authorized to bind the party;
Expressly requires each member of the group to participate in MIPS as a virtual group and comply with MIPS requirements and other applicable laws and regulations;
Identifies each NPI under each TIN in the virtual group and notify all NPIs regarding their participation in the virtual group;
Sets forth the NPI’s rights and obligations in, and representation by, the virtual group;
Describes how the opportunity to receive payment adjustments will encourage each member of the virtual group to adhere to quality assurance and improvement;
Require each party to update its Medicare enrollment information and notify the virtual group of any changes within thirty (30) days after the change;
Be for a term of at least one performance period; and
Requires completion of a close-out process upon termination or expiration of the agreement to furnish all data necessary for the virtual group to aggregate its data across the group.
(42 C.F.R. §414.1315(c)(3).) For a virtual group agreement checklist and a sample agreement, download the CMS 2018 Virtual Groups Toolkit at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Resources-by-topic.html.
Why join or form a virtual group?
According to CMS, solo practitioners or groups with ten (10) or fewer eligible clinicians may not have enough cases to be reliably measured on their own, but together they could increase the performance volume in order to be reliably measured. In addition, the formation of virtual groups provides shared responsibility and an opportunity to effectively and efficiently coordinate resources to achieve requirements under each performance category.
How do MIPS eligible clinicians submit MIPS data to CMS?
Individuals and groups may elect to submit their MIPS data for the Quality, Improvement Activities, or Advancing Care Information performance categories using the following mechanisms:
A qualified registry which is defined as “a medical registry, a maintenance of certification program operated by a specialty body of the American Board of Medical Specialties or other data intermediary that, with respect to a particular performance period, has self-nominated and successfully completed a vetting process (as specified by CMS) to demonstrate its compliance with the MIPS qualification requirements specified by CMS for that performance period”;
EHR submission mechanism, which includes submission of data by health IT vendors or other authorized providers on behalf of the MIPS eligible clinician;
A qualified clinical data registry (QCDR) that has been approved by CMS to collect medical and clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients;
CMS Web Interface. Groups comprised of 25 or more MIPS eligible clinicians can also send data for all three performance categories through a CMS Web Interface. (42 C.F.R. §414.1325(c).) To submit data through the CMS Web Interface for the 2018 performance year, the group must register with CMS between April 1 and June 30, 2018. If your group registered for the CMS Web Interface in 2017, CMS automatically registered your group to use it in 2018 for MIPS. Registered groups that wish to participate through another data submission option should cancel its election in the registration system between April 1 and June 30, 2018. Groups should also ensure that the group information is updated during that period. To register or update group information, groups must have a valid Enterprise Identity Management account; and
Attestation for Improvement Activities and Advancing Care Information performance categories.
MIPS eligible clinicians submitting data as an individual can also send data for the Quality performance category through routine Medicare Part B claims. (42 C.F.R. §§414.1305 and 414.1325.)
Consumer Assessment of Healthcare Providers and Systems (CAHPS). Groups or virtual groups with two (2) or more eligible clinicians (but not individual clinicians) have the option to elect to include the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey to supplement its Quality reporting. The CAHPS for MIPS survey measures patient experience and care within a group and can be submitted on behalf of the group by a CMS-approved survey vendor. (42 C.F.R. §414.1325.)
For more information on the CMS Web Interface and the CAHPS for MIPS Survey, see CMS Quality Payment Program website at https://qpp.cms.gov/mips/individual-or-group-participation/about-group-registration.
Does MIPS data from all three performance categories have to be submitted via the same mechanism?
No. While MIPS eligible clinicians and groups may submit information via multiple mechanisms, the same identifier for all performance categories must be used and they may only use one submission mechanism per performance category. (42 C.F.R. §414.1325(d).)
When does the data need to be submitted?
MIPS eligible clinicians and groups must submit data by March 31 following the end of the performance period. For Medicare Part B claims, data must be submitted on claims with dates of service during the performance period that must be processed no later than sixty (60) days following the end of the performance period. For groups using the CMS Web Interface, data must be submitted during an 8-week period between January 2 and March 31 following the close of the performance period. (42 C.F.R. §414.1325(f).) For the 2017 performance period, data must be submitted by March 31, 2018. For the 2018 performance period, data must be submitted by March 31, 2019.
When do payment adjustments under MIPS begin?
While the physician fee schedule payments will automatically increase by 0.5 percent beginning in 2017 through 2019, the first payment adjustments based on performance measures results go into effect on January 1, 2019. (42 C.F.R. §414.1405.) There will be no automatic increases to the physician fee schedule payments between 2020 and 2025. The annual payment increase will be reinstated at 0.25 percent for MIPS participants starting in 2026.
What are the maximum positive payment adjustments and maximum payment penalties under MIPS?
Physician payments under MIPS will be adjusted positively or negatively based on a composite score calculated from performance measure results. The potential maximum adjustment, positive or negative, increases every year as follows:
2019: +/- 4 percent
2020: +/- 5 percent
2021: +/- 7 percent
2022 and each subsequent year: +/- 9 percent
Note that these numbers are the maximum up or down adjustment and a clinician’s particular adjustment can fall anywhere within that range. MIPS is designed to be a budget-neutral program, which means that the payment adjustments are determined on a curve, requiring providers to be measured against each other to determine who qualifies for a payment increase or decrease. Physicians also have the potential to receive up to an additional 10 percent bonus, funded from a total annual pool of $500 million, for exceptional performance for payment years 2019 through 2024. (42 C.F.R. §414.1405.).
How can MIPS eligible physicians avoid a negative payment adjustment in 2019?
Recognizing that physicians may face challenges in understanding the requirements and participating in the Quality Payment Program, CMS allowed physicians to pick their pace of participation for the 2017 performance period (2017 MIPS transition year) during the initial development and transition to MIPS. By choosing one of following three reporting options under MIPS, physicians may receive a positive payment adjustment and avoid a negative payment adjustment in 2019.
MIPS Testing. Report either one quality measure, one improvement activity, or one required measure in the advancing care information performance category at any time during 2017 and avoid the payment penalty;
Partial Reporting. Submit partial MIPS data for at least 90 days during the 2017 reporting period and report more than one Quality measure, more than one Improvement Activity, or more than the required measures in the Advancing Care Information performance category to receive a possible positive payment adjustment.
Full Reporting. Meet all reporting requirements for at least 90 consecutive days, or ideally, the full year, during the 2017 reporting period. Opportunity for the maximum positive payment adjustment of 4 percent in 2019. Exceptional performances are eligible for additional bonus adjustment of up to 10 percent.
(81 Fed.Reg. at 77011.) MIPS eligible clinicians who do not submit any data for the 2017 performance period will receive the maximum 4 percent negative payment adjustment.
What if a MIPS eligible physician was unable to collect or submit data due to the California wildfires?
For the 2017 performance year, CMS will also grant an automatic hardship exemption for physicians affected by extreme and uncontrollable circumstances such as hurricanes, natural disasters, or public health emergencies. CMS will identify physicians affected by the California wildfires based on information in the Provider Enrollment, Chain and Ownership System (PECOS). CMS has identified the following California counties designated as a major disaster county by the Federal Emergency Management Agency: Butte, Lake, Mendocino, Napa, Nevada, Orange, Santa Barbara, Solano, Sonoma, Ventura, and Yuba counties. Clinicians in these counties will be granted the hardship exception without having to submit a request. Thus, clinicians in affected areas who do not submit any data will not be subject to a negative payment adjustment in the 2019 payment year. Clinicians who do submit data will be scored on their submitted data and be rewarded for their performance. For more information, see The Extreme and Uncontrollable Circumstances Policy for the Merit-based Incentive Payment System (MIPS) in 2017 available on the CMS website at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Interim-Final-Rule-with-Comment-fact-sheet.pdf.
How can MIPS eligible physicians avoid a negative payment adjustment in 2020?
For the 2018 performance period, physicians may receive a positive payment adjustment and avoid a negative payment adjustment in 2020 by picking one of the following options:
Basic MIPS. Submit MIPS data for at least 90 days during the 2018 reporting period for Improvement Activities and Advance Care Information performance categories along with a full year of Quality data. Report enough data to earn at least 15 points by submitting measures under the Quality and Improvement Activity performance categories or required measures in the Advancing Care Information performance category during 2018 and avoid the negative 5 percent payment penalty. Clinician who submit enough data to earn additional points and receive a possible positive payment adjustment.
Maximizing MIPS. Meet all reporting requirements for the full year during the 2018 reporting period. Opportunity for the maximum positive payment adjustment of 5 percent in 2020. Exceptional performances are eligible for additional bonus adjustment of up to 10 percent.
(42 C.F.R. §414.1405.) See How to Avoid a Penalty in 2018 MIPS Program, available on the AMA website at www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/mips-scoring-sheet-avoid-penalty.pdf.
Will physicians continue to be subject to payment penalties under the existing legacy programs?
Payment penalties under PQRS, VM, and the Medicare EHR Incentive Program will apply in 2017 and 2018 based on reporting for the 2015 and 2016 performance periods respectively. MIPS sunsets the payment adjustment penalties under the legacy programs on December 31, 2018 with the payment adjustments under MIPS beginning in 2019. (42 U.S.C. §1395w-4(a).)
Do physicians transitioning to MIPS need to attest to Meaningful Use to avoid a payment penalty under the EHR Incentive Program in 2018?
It depends. If the eligible professional has never before successfully attested to meaningful use under the Medicare EHR Incentive Program, they may submit a hardship form to avoid the 2018 payment adjustment based on the 2016 EHR reporting period if they intend to 1) attest to meaningful use for the 2017 EHR reporting period; 2) transition to MIPS in 2017; and 3) report on measures specified for the Advancing Care Information Performance Category under MIPS in 2017. Eligible professionals who meet these criteria will have had to attest to Meaningful Use for the 2016 EHR reporting period and submitted an application for this one-time exception by October 1, 2017 to avoid the payment penalty under the EHR Incentive Program in 2018. (45 C.F.R. §495.102.)
Physicians who have successfully demonstrated meaningful use in the past, but failed to do so during the 2016 reporting period must have submitted a standard Hardship Exception Application by July 1, 2017. For more information, including instructions to submit the Hardship forms and the applications, visit the CMS Payment Adjustments & Hardship Information website at www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/paymentadj_hardship.html.
For more information on the federal EHR Incentive Programs, see CMA ON-CALL document #4301, "Electronic Health Records: Federal Incentive Programs,"Chapter 14, section entitled “Electronic Health Records: Federal Incentive Programs,” CMA ON-CALL document #4302, "Meaningful Use of Electronic Health Records: 2015–2018 Modifications to Stage 1 & 2,"Chapter 14, section entitled “Meaningful Use of Electronic Health Records: 2015–2018 Modifications to Stage 1 & 2,” and CMA ON-CALL document #4305, "Meaningful Use of Electronic Health Records (EHRs): Stage 3."
Does MIPS affect the Medi-Cal EHR Incentive Program?
No. Changes under MACRA related to the Quality Payment Program do not affect the Medicaid or Hospital EHR Incentive programs.
What are MIPS APM?
Alternative Payment Models or APMs are part of a broader push to reform the healthcare system to embrace innovative approaches to improve the quality and value of the care delivered with a focus on better care, smarter spending, and healthier people. APMs work toward these goals through payment arrangements that go beyond fee-for-service billing and give incentive payments to provide high quality, cost-efficient care. Examples of APMs can include accountable care organizations, patient-centered medical homes, bundled payment models, and episode and condition-based models. Physicians that participate in a subset of APMs that meet specified criteria to be an Advanced APM and achieve threshold levels of payments or patients through Advanced APMs can qualify as a Qualifying APM Participant (QP) and earn fee schedule increases and bonus payments under the Advanced APM track of the Quality Payment Program in exchange for taking on some risk related to patient outcomes.
The Affordable Care Act (ACA) included a number of provisions designed to improve the quality of Medicare services, support innovation and the establishment of new payment models, and better align Medicare payments with provider costs. The ACA established CMS’s Innovation Center to select and test promising innovative payment and service delivery models, including APMs. (42 U.S.C. §1315a.) The Innovation Center plays a critical role in implementing the Quality Payment Program by testing and evaluating APMs, both with Medicare as the payor as well as other payors, and working with stakeholders to increase the number and variety of models available to provide more opportunities for a wide range of physician practices to participate in the Advanced APM track. For more information, visit the Innovation Center website at https://innovation.cms.gov/
What are the criteria for an APM to be an Advanced APM?
How will I know if CMS determines an APM to be an Advanced APMs?
Bundled Payments for Care Improvement Advanced Model (BPCI Advanced) (https://innovation.cms.gov/initiatives/bpci-advanced/);
Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1—CEHRT) (https://innovation.cms.gov/initiatives/cjr);
Comprehensive ESRD Care (CEC) Model (LDO arrangement) (https://innovation.cms.gov/initiatives/comprehensive-ESRD-care/);
Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement) (https://innovation.cms.gov/initiatives/comprehensive-esrd-care/);
Comprehensive Primary Care Plus (CPC+) Model (https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus);
Next Generation ACO Model (https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/);
Medicare Shared Savings Program Accountable Care Organizations—Track 2 (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html);
Medicare Shared Savings Program Accountable Care Organizations—Track 3 (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html);
Oncology Care Model (OCM) (two-sided risk arrangement) (https://innovation.cms.gov/initiatives/oncology-care/); and
Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) (https://innovation.cms.gov/initiatives/vermont-all-payer-aco-model/).
What is a Medical Home Model under the Quality Payment Program?
A medical home model means an APM that CMS has determined to have the following:
A primary care focus with participants that mainly include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services. Primary care focus means the inclusion of eligible clinicians practicing under one or more the following Physician Specialty Codes: General Practice (01); Family Medicine (08); Internal Medicine (11); Obstetrics and Gynecology (16); Pediatric Medicine (37); Geriatric Medicine (38); Nurse Practitioner (50); Clinical Nurse Specialist (89); and Physician Assistant (97).
Empanelment of each patient to a primary clinician; and
At least four of the following: 1) Planned coordination of chronic and preventative care; 2) Patient Access and continuity of care; 3) Risk-stratified care management; 4) Coordination of care across the medical neighborhood; 5) Patient and caregiver engagement; 6) Shared decision-making; or 7) Payment arrangements in addition to, or substituting for, fee-for-service payments (for example, shared savings or population-based payments).
(42 C.F.R. §414.1305.) Medical Home Models under Medicare and Medicaid have different financial risk and nominal amount standards compared to other APM arrangements.
Are all APMs Medicare APMs?
No. A payment arrangement with a payor other than Medicare is considered an Other Payer Advanced APM if CMS determines that the arrangement meets the criteria for an Other Payer Advanced APM, which are similar, but not identical, to the criteria for Advanced APMs under Medicare. For instance, the nominal amount standard is different for Other Payer Advanced APMs. Beginning with the 2019 performance period, payors can submit the following types of payment arrangements for consideration for Other Payer Advanced APMs: Medicaid APMs and Medicaid Medical Home Models; CMS multi-payer models; and Medicare health plans (including Medicare Advantage, Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and PACE). CMS will consider commercial and other private payors for the Other Payer Advanced APM option in future years. (42 C.F.R. §§414.1420 and 414.1445.)
For more information on the Other Payer Advanced APM Determination Process, see Quality Payment Program – Final Rule for Year 2 Other Payer Advanced APM Determination Process – Medicaid, available on the CMS website at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/APMs-Medicaid-Models-and-All-Payer-Models.pdf.
Advanced APM Payments
What are the benefits of Advanced APM participation?
Physicians who participate in Advanced APMs and achieve threshold levels of payments or patients through Advanced APMs are exempt from reporting requirements and payment adjustments under MIPS, receive a 5 percent lump sum annual bonus payment between 2019 through 2024, and receive a higher annual baseline payment increase (0.75 percent) compared to MIPS participants (0.25 percent) starting 2026. (42 C.F.R. §§414.1305 and 414.1450; 42 U.S.C. §1395w-4(d)(20).)
How does an eligible clinician qualify for the bonus incentive amount and the higher annual baseline payment increase?
To qualify for the 5 percent APM incentive payment and the higher annual baseline payment increase for participating in an Advanced APM, an eligible clinician must be a Qualifying APM Participant (QP). An eligible clinician is a QP for a year if the eligible clinician is in an APM Entity group that collectively receives a certain percentage of payments for covered professional services or sees a certain percentage of patients through the Advanced APM during the performance year. (42 C.F.R. §§414.1425 and 414.1450.)
Medicare option. For the 2017 and 2018 performance years, eligible clinicians must meet one of the following Threshold Scores:
Receive 25 percent of Medicare payments through an Advanced APM; or
See 20 percent of Medicare patients through an Advanced APM.
The Threshold Scores increase in subsequent performance years. (42 C.F.R. §414.1430.)
All-payer combination option. If an eligible clinician does not meet the Threshold Scores to become a QP based only on participation in Advanced APMs with Medicare, starting in the 2019 performance year, they can also count their participation in Other Payer Advanced APMs to potentially become a QP for the year and earn the bonus payment. Beginning with the 2019 performance period, payors can submit the following types of payment arrangements to meet the criteria as an Other Payer Advanced APM:
CMS will consider commercial and other private payors for the Other Payer Advanced APM option in future years. Under this all-payer combination option, eligible clinicians must first be in a Medicare Advanced APM before a payment arrangement with non-Medicare payors will be considered. (42 C.F.R. §§414.1420, 414.1445, and 414.1440.) Eligible clinicians must meet an alternative threshold that will include non-Medicare payments and patients to qualify for the 5 percent bonus. (42 C.F.R. §414.1430.) For more information on the all-payer combination option, see Quality Payment Program Year 2 Final Rule All-Payer Combination Option & Other Payer Advanced APMs, available on the CMS website at www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/All-Payer-Combination-Option-and-Other-Payer-Advanced-APMs.pdf.
What is a Partial Qualifying APM Participant?
While a Qualifying APM Participant has met or exceeded the relevant payment amount or patient count threshold described above, a Partial Qualifying APM Participant is an eligible clinician who meets a lower threshold of Medicare payments or patients. Under the Medicare option, in the 2017 and 2018 performance period, eligible clinicians must meet one of the following Threshold Scores:
Receive 20 percent of Medicare payments through an Advanced APM; or
See 10 percent of Medicare patients through an Advanced APM.
The Threshold Scores increase in subsequent performance years. (42 C.F.R. §414.1430.) Partial Qualifying APM Participants will not receive the 5 percent bonus incentive payment, however, Partial Qualifying APM Participants are not required to report under MIPS and are not subject to the payment adjustments under MIPS. Partial Qualifying APM Participants may choose to participate in MIPS and be scored using the MIPS APM scoring standard, wherein different weights are assigned to the performance categories that are more favorable for participants of these APMs when calculating the composite score. (42 C.F.R. §414.1370.)
When will clinicians learn their qualified participant status for APMs?
During the Qualifying APM Participant Performance Period (January 1–August 31 two years prior to the payment year), CMS will take three “snapshots” (March 31, June 30, August 31) to determine which eligible clinicians are participating in an Advanced APM and whether they meet the Threshold Scores to become Qualifying APM Participants. For those Advanced APM participants, CMS will make three Qualifying APM Participant determinations based on claims data for services furnished from January 1 through each of the three snapshot dates. Reaching the Threshold Score at any of the “snapshots” will result in Qualifying APM participant status for the eligible clinicians in the Advanced APM entity. (42 C.F.R. §§414.1305 and 414.1425(b).)
Are there any negative payment adjustments for Qualifying APM Participants?
No. There are no negative payment adjustments for Advanced APMs.
A physician-focused payment model is an APM in which Medicare is a payor, the eligible clinicians are participants and play a central role in implementing the APM’s payment methodology, and targets the quality and costs of services that clinicians participating in the APM provide, order, or can significantly influence. (42 C.F.R. §414.1465.) A Physician-Focused Payment Model Technical Advisory Committee (PTAC) reviews and assesses these models based on proposals submitted by stakeholders to the Committee. PTAC provides an opportunity for physicians to have a key role in the development of new APMs.