Merit Based Incentive Payment Systems (MIPS) APMs

What is an alternative payment model (APM)?

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

What is a MIPS APM?

A Merit Based Incentive Payment System (MIPs) APM is a subset of Medicare APMs that utilized a special scoring standard to determine a group practice’s MIPS composite performance score. Participants in MIPS APMs are not eligible for the 5% lump sum bonus through 2024.

What is the APM scoring standard?

The scoring standard is designed to account for activities that are already required by the APM which eliminates the need for the MIPS clinicians to submit performance data multiple times. CRNAs with a signed MIPS Participation Agreement will have their MIPS performance data submitted on their behalf as required by the terms set forth in the APM Entity’s agreement with CMS.

What is the APM Scoring Standard Criteria?

There are three criteria: (1) APM entities participate in the MIPS APM under an agreement with CMS; (2) The MIPS APM requires APM Entities to include at least one MIPS eligible clinician on a Participation List; and (3) The MIPS APM bases performance payment incentives on quality measures and cost/utilization. (Note: CMS updated this definition for CY 2019 to clarify that a MIPS APM must be designed in a way that participating APM entities are incentivized to reduce cost of care or utilization of services, or both. This change emphasizes that the cost/utilization policy is broader than simply requiring the use of cost/utilization measures.)

 


What are Participation Determinations and Snapshot Dates?

CMS will take four “snapshots” during the performance period to determine which eligible clinicians (ECs) are on a MIPS APMs Participation List. They are March 31st, June 30th, August 31st and December 31st of each performance year. CMS added a fourth “snapshot” date of December 31 that applies only to ECs in Medicare Shared Savings Accountable Care Organizations (ACOs) to determine which ECs joined the ACO between September 1st and December 31st of the performance year. The December 31st date will not be used to make Qualified Participant (QP) determinations.

What is the 2019 Scoring Standard for MIPS APMs?

Generally, most ECs participating in MIPS APMs will have their performance categories weighted in the following manner: Quality=50%; Improvement Activities (IA)=20%; Promoting Interoperability (PI), formerly known as Advancing Care Information=20%; and Cost=0%.

How will the scoring standard be applied to ECs in a MIPS APM?

ECs in MIPS APMs will have their performance score scored at the APM Entity Group level and each EC will receive the APM Entity Group’s final score.

How will the MIPS APM payment adjustment be applied for an EC in a MIPS APM?

The MIPS APM payment adjustment will be applied at the TIN/NPI level for each EC in the MIPS APM.

 

Medicare Advanced APMs

What is an Advanced APM?

Advanced APMs are a subset of APMs that let group practices and clinicians earn more for taking on some risk related to their patient outcomes. Eligible clinicians may earn an incentive payment by going further in improving patient care and taking on risk through an advanced APM.

What are the criteria to be considered a Medicare Advanced APM Model?

There are three requirements for an APM to be considered an Medicare Advanced APM: (1) Requires 75 percent of ECs in each APM entity to use a certified electronic health record technology (CEHRT) for performance year 2019; (2) Provides payment for covered professional services based on quality measures comparable to those used in the Quality performance category of the MIPS Program; and (3) Participates in either a Medical Home Model expanded under the CMS Innovation Center, or an APM entity that bears financial risk based on the revenue-based nominal standard amount of 8 percent.

How may an EC earn an incentive bonus payment by participating in a Medicare Advanced APM?

ECs who are deemed Qualified Participants (QPs) AND meet certain payment or patient thresholds may earn a 5 percent incentive bonus on their Medicare Part B billings. Performance Year 2022 will be the last performance period for which ECs can earn the 5 percent incentive bonus through advanced APM participation.

How does an EC meet the payment or patient threshold levels for full QP status?

CMS sets the annual Medicare payment and patient threshold levels for each performance year. For example, in 2019 an EC must meet 50% of Medicare payment or 35% of Medicare patients to qualify as a full QP.  If the EC meets the full QP status based on the CMS determined eligibility thresholds, then the EC receives the incentive bonus in the payment year that is two years after the performance year (e.g. performance year 2019, payment year 2021.) If an EC does not meet the annual payment or patient threshold levels set for full QP status based on the Medicare thresholds, the EC may be able to still earn partial QP status.

CMS sets the annual Medicare payment and patient threshold levels for each performance year. For example, in 2019 an EC must meet 50% of Medicare payment or 35% of Medicare patients to qualify as a full QP. If the EC meets the full QP status based on the CMS determined eligibility thresholds, the EC receives the incentive bonus in the payment year that is two years after the performance year (e.g. performance year 2019, payment year 2021.) If an EC does not meet the annual payment or patient threshold levels set for full QP status based on the Medicare thresholds, the EC may be able to still earn partial QP status.

What are the benefits of Partial QP status?

Partial QPs in an Advanced APM may elect to participate in MIPS and will have their score calculated through the APM Scoring Standard. (See 2019 MIPS APM answers above.) Absent an express election to participate in MIPS, a Partial QP will automatically be excluded from MIPS.

When are QP status determinations made?

CMS will take three “snapshots” during the QP performance period to determine which ECs are participating in an Advanced APM and whether they meet the threshold levels to become QPs or partial QPs. The “snapshot” dates are March 31st, June 30th, and August 31st of each performance year.

Can QP status be determined at the individual level?

Generally, QP status is determined at the APM Entity level. CMS will determine QP status at the individual level in the following situations: (1) the CRNA participates in multiple Advanced APMs, none of which collectively meet the QP threshold, or (2) when the Advanced APM includes ECs only on an Affiliated Practitioner List. This only occurs after the Final QP determinations for a calendar year.

 


All Payer Combination Advanced APMs

What other ways can an eligible clinician in a Medicare Advanced APM become a Qualified Participant if they don’t meet the Medicare payment or patient thresholds?

The Advanced APM path has two ways for eligible clinicians (ECs) (e.g. CRNAs) to become a QP: (1) the Medicare Option, which looks only at an EC’s participation in Medicare Advanced APMs; and (2) The All-Payer Option, which takes into consideration an EC’s participation in Medicare Advanced APMS and Other Payer Advanced APMs  (e.g. Medicaid, Medicare Advantage (MA) APMs, and other commercial and private payer arrangements) that meet the Other Payer Advanced APM criteria.

What is the All-Payer Combination Advanced APM option?

The All-Payer Combination option allows ECs participating in both Medicare Advanced APMs and Other Payer APMs to attain Qualified Participant (QP) status.  Other Payer Advanced APMs include, but are not limited to: Medicaid, Medicare Advantage (MA) APMs, and other commercial and private payer arrangements that meet the Other Payer Advanced APM criteria.

What is the purpose of the All-Payer Combination Option?

The All-Payer Combination option allows ECs participating in a Medicare Advanced APMs to also use their participation in an Other Payer Advanced APMs to attain Qualified Participant (QP) status. ECs who do not meet the patient or payment threshold under the Medicare Option, but do meet a Medicare minimum threshold, may ask for a QP determination under the All-Payer Combination Option. CMS notes that QP determinations will be done sequentially, meaning the Medicare Option will always be applied before the All-Payer Combination Option.

How does an Advanced APM become an Other Payer Advanced APM under the All-Payer Combination Option?

Under the All-Payer Combination Option, State Medicaid Agencies, Medicare Advantage and other Medicare Health Plans, as well as commercial and private payers participating in CMS-sponsored Multipayer payment arrangements may submit information to CMS about their payment arrangements with ECs prior to a performance year. CMS will then determine whether each payer arrangement constitutes an Other Payer Advanced APM and will approve it as such. This is called the Payer Initiated Process.

What criteria must the APM entity fulfill in order for it to be considered in an Other Payer Advanced APM?

The criteria for an Other Payer Advanced APM is similar to but not exactly the same as the criteria to become a Medicare Advanced APM. The APM entity must meet the following criteria to be considered a participant in a CMS approved Other Payer Advanced APM are: (1) For performance year 2019, the APM entity must have 50% of its eligible clinicians in each Other Payer APM use certified electronic health record technology (CEHRT) to document and communicate clinical care information; (2) Provides payment for covered professional services based on quality measures comparable to those used in the Quality performance category of the Merit-based Incentive Payment Systems (MIPS) Program that are evidence-based, reliable and valid quality measures with at least one outcome measure if available; and (3) Participates in either a Medicaid Medical Home comparable to the Medical Home Models expanded under CMS Innovation Center authority; or an APM entity that bears financial risk based on the revenue-based nominal standard amount of eight percent.

What if a payer, such as Medicaid Advanced APM, does not submit payer information to CMS for approval to be an Other Payer Advanced APM?

If a payer chooses not to submit payer information to CMS, ECs or APM entities participating in the payment arrangement may do so. This is the other approval process CMS utilizes to approve an APM to become an Other Payer in the All-Payer Combination Option. This process is called the Eligible Clinician Initiated Process.

How will I know if the APM entity that I am participating in is approved to be an Other Payer Advanced APM under the All-Payer Combination Option?

CMS will publish its list of approved Other Payer Advanced APMs on QPP.cms.gov.

Can ECs who are QPs in the All-Payer Combination Advanced APM option qualify for the APM five percent incentive bonus?

ECs who are determined to be Qualified Participants (QP) in performance year 2019, through a combination of Medicare Advanced APMs and All-Payer Advanced APMs may earn a five percent incentive bonus in the 2021 payment year.

How does an EC attain QP status in the All-Payer Combination Option?

QP status is based on whether a clinician meets or exceeds annual patient or payment threshold levels in an APM entity that also participates in an Advanced APM. In performance year 2019, ECs who do not meet the patient or payment threshold under the Medicare Option, but do meet a Medicare minimum threshold, may ask for a QP determination under the All-Payer Combination Option.

Do ECs trying to achieve QP status have to participate in Medicare Advanced APMs to utilize the All-Payer Combination Option?

Yes. The All-Payer Combination Option does not replace or supersede the Medicare Option. QP determinations will be done sequentially meaning the threshold calculations for the Medicare Option will always be applied before the threshold calculations for the All-Payer Combination Option.

What are the advantages of attaining partial QP status under the All-Payer Combination Option?

ECs who achieve Partial QP status can decide whether to participate in MIPS via the Special Scoring Standard. Absent an express election to participate in MIPS, a Partial QP will automatically be excluded from MIPS and will not be subject to the upward or downward payment adjustment.


CMS Quality Payment Program

Quality Payment Program (website)