• MIPS Manual 2017—The Alternative to MIPS: APMs in Brief

    Written By: Sarah Cartagena

    This content was excerpted from EyeNet’s MIPS Manual 2017.

    There are 2 ways to participate in Medicare’s Quality Payment Program: 1) via MIPS, which is the pathway that most ophthalmologists will take this year, and 2) as an advanced alternative payment model (APM).

    What is an APM? APMs are voluntary models that change the way CMS pays physicians. They add incentives that are intended to reward high-quality, cost-effective care. Some examples may include accountable care organizations, patient-centered medical homes, and bundled payment models.

    What is an advanced APM? CMS defines an advanced APM as a model that:

    1. requires participants to use certified EHR technology (CEHRT);
    1. provides payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS; and
    1. either (A) is a Medical Home Model expanded under CMS Innovation Center authority or (B) requires participating APM entities to bear more than a nominal amount of financial risk for monetary losses.

    In the MIPS regulations, CMS listed 6 models that would qualify as an advanced APM starting in 2017:

    • Comprehensive End Stage Renal Disease Care Model
    • Comprehensive Primary Care Plus
    • Medicare Shared Savings Program (tracks 2 and 3)
    • Next Generation ACO Model
    • Oncology Care Model (OCM) 2-Sided Risk Arrangement

    What is a qualifying APM participant (QP)? A QP is a MIPS eligible clinician determined by CMS to have met or exceeded the relevant QP payment amount threshold or QP patient count threshold for a year based on participation in an advanced APM entity. QPs can qualify for a 5% Medicare Part B incentive payment. These clinicians would also be exempt from MIPS payment adjustments for payment years 2019-2024.

    What is a partial qualifying APM participant (partial QP)? A partial QP is a MIPS eligible clinician determined by CMS to have met the relevant partial QP threshold for a year. CMS has established lower thresholds for partial QP status. This status allows these clinicians to opt out of the MIPS payment adjustments but does not confer all the benefits of QP status. CMS is providing “partial credit” to encourage participation in advanced APM entities even if that participation is not sufficient to earn the APM bonus.


    What is a MIPS APM? APMs that don’t qualify as “advanced” are evaluated as MIPS APMs. These hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. In addition, MIPS eligible clinicians who are participating in an advanced APM and do not meet the QP threshold are scored under MIPS according to the APM scoring standard.

    Different reporting requirements and scoring. These models can have MIPS data submission requirements and MIPS category scoring weights differing from those of other MIPS eligible clinicians. For MIPS APMs, the performance categories are weighted as follows—quality contributes up to 50 points; ACI contributes up to 20 points; and improvement activities contribute up to 30 points.

    Different types of MIPS APM. CMS listed 8 models in their final rule that would qualify as a MIPS APM:

    • Comprehensive End Stage Renal Disease Care Model (all arrangements)
    • Comprehensive Primary Care Plus
    • Medicare Shared Savings Program (tracks 1, 2, and 3; note that track 1 did not qualify as an advanced APM)
    • Next Generation ACO Model
    • Oncology Care Model (1- and 2-Sided Risk Arrangement)

    MIPS tip. If you are part of an ACO that is considered a MIPS APM, you should report quality measures independently of the ACO and can do so using the IRIS Registry. If the ACO is successful in its MIPS reporting, CMS will ignore the quality measures that you reported. But if your ACO is unsuccessful in its MIPS reporting, your quality reporting can safeguard you from the 4% payment penalty.

    All Payer Combination

    Starting in performance year 2019 (payment year 2021), your MIPS eligible clinicians may become QPs through a combination of participation in advanced APMs and other payer advanced APMs. This will be known as the All Payer Combination option. This option would allow eligible clinicians to become QPs by meeting a relatively low threshold based on Medicare Part B covered professional services through advanced APMs and an overall threshold based on services through both advanced APMs and other payer advanced APMs. Medicare Advantage plans will be considered under this option.


    Next: Your 8-Step To-Do List for MIPS Resources

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

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