Over the past few years many providers have begun to participate in an ACO of some kind. Often, these ACO models are attached to the hospital that they are most affiliated with or a larger health system. This arrangement allowed for providers to participate in a quality program while also allowing them to meet their PQRS requirements for quality reporting. Then along came MACRA……
What is a MIPS Advanced Payment Model?
The MACRA ruling not only includes MIPS (Merit-Based Incentive Payment System) but also something called an Advanced Alternative Payment Model (APM). There are several requirements that these payment models have to meet to be considered a true APM. There are only a few of these types of programs in the country and CMS expects that only between 30,000 – 90,000 clinicians will be included in this part of the program.
However, there is an alternative. In 2017, some APMS, by virtue of their structure, will not meet the requirements to be categorized as an Advanced Alternative Payment Model. Because of this, Eligible Clinicians who are participating in these types of APMs are subject to the MIPS payment adjustment. These types of Advanced Alternative Payment Models are referred to as MIPS APMs and are the main topic of our discussion today.
How Do You Know if Your APM is Advanced or Not?
CMS has released a list of all of the Alternative Payment Models along with a breakdown of the participation level. You can use this list to find the program that you participate in along with the status of an Advanced APM or a MIPS APM. Once you have this key information you can move forward with the planning for your organization.
Understanding the MIPS APM
Who is Eligible?
It is important to review your current relationship with your APM. Under the MACRA Final Rule, an Eligible Clinician can only use the MIPS APM reporting mechanism if they are a Participant of the program. They must actually be included on the participation list to fall under this scoring method. If they are listed only as a “Preferred Provider” under a business arrangement with the APM, the Eligible Clinician will need to report under MIPS and not the MIPS APM.
There will be a period review of the participation list from CMS. If an Eligible Clinician is listed as a participant on at least one of these dates, they will be considered as participating and can report under the MIPS APM reporting option.
- March 31
- June 30
- August 31
Once an Eligible Clinician is determined to be part of the APM group at one of the snapshot dates, they will be part of the group for purposes of MIPS and the APM scoring will be used for that performance period even if they leave the APM at a later date.
If you think you are participating in an APM but are not certain that your clinicians are on the “Participation” list, I would advise you contact your program administrator. If the Eligible Clinicians are not listed on one of the above dates, you will have to report them as individuals or a as group under MIPS.
How is the Scoring Different from MIPS?
The scoring for the MIPS APMs can be quite confusing. Within the MIPS APMS there are slightly different scoring options for:
- Shared Savings Program ACO
- Next Generation ACO
- Other MIPS APMs
Shared Savings Program ACO
The below table highlights the details of each component of the program and how the ACO and the Eligible Clinician will report for MIPS.
Next Generation ACO
This APM is scored very similarly to the Shared Savings Program ACO, except for the Advancing Care Information. There are a few slight differences as you can see in the table below.
Other MIPS Advanced Payment Models
There are some operational hurdles that CMS has to work out in combining the current quality data collection for these ACOs to the MIPS program. For this reason, the quality performance category for these types of APMs is weighted to zero. The majority of the focus is put into Improvement Activities and Advancing Care Information.
As you can see, this is a complicated process. The most important thing you can do right now is to determine the type of Advanced Payment Model you are working with and verify that your Eligible Clinicians are Participants in the Program.