Advanced Alternative Payment Models (APMs)

The Centers for Medicare & Medicaid Services (CMS) has issued a “payment advisory” alerting approximately 1,400 clinicians who are Qualifying APM participants based on their 2017 performance that CMS does not have the participants’ banking information.  This banking information is necessary for CMS to disburse their 5% Advanced APM Incentive Payments for 2019. 

CMS is planning a new “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration” that would allow clinicians who participate in certain Medicare Advantage (MA) plans that involve taking on risk to be treated as Advanced Alternative Payment Model (Advanced APM) participants under the Medicare physician fee schedule. By way of background, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established two tracks for Medicare physician fee schedule/Quality Payment Program updates:

  1. The Merit-based Incentive Payment System (MIPS), which adjusts Medicare payments based on performance on quality, cost, improvement activities, and advancing care information measures, or
  2. Advanced APMs, under which eligible clinicians may earn incentive payments for sufficient participation in certain payment arrangements that coordinate care, improve quality, and reduce costs.

Continue Reading CMS Considering New Medicare Advantage Payment Arrangement Incentive (MAQI) Demonstration

CMS has issued a final rule with comment period making changes to the Quality Payment Program (QPP) for 2018, the second performance year for the reformed physician payment framework mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS is continuing its “slow ramp-up” of the QPP by building on the transition policies established for 2017. In the 2018 rule, CMS intends to encourage successful QPP participation under either the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM) track while reducing burdens on clinicians.

With regard to MIPS participation, the final rule:

  • Reweighted the performance category scoring for 2018 as follows: Quality 50%, Cost 10%, Improvement Activities 15%, and Advancing Care Information 25%.
  • Increased the performance threshold to 15 points in year two (up from 3 points in 2017).
  • Established a Virtual Groups participation option under which solo practitioners and groups of 10 or fewer eligible clinicians that exceed the low-volume threshold may come together “virtually” to participate in MIPS for a one-year performance period.
  • Increased the low-volume threshold to less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries (up from $30,000 charges/200 beneficiaries) in order to exclude more practices.
  • Provided bonus points for: the treatment of complex patients; use of only the 2015 Edition Certified Electronic Health Record Technology; and clinicians and small practices that submit data on at least one performance category in an applicable performance period.
  • Implemented an optional facility-based scoring mechanism for facility-based clinicians, beginning with the 2019 performance year.
  • Created hardship exemptions in the Advancing Care Information performance category.
  • Added a new improvement activity for clinicians who attest to consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for outpatient advanced diagnostic imaging services ordered (applicable to clinicians who are early adopters of the Medicare AUC program in the 2018 performance year and for clinicians who begin the Medicare AUC program in future years as specified in separate regulations).
  • Promulgated an interim final rule with comment period to address extreme and uncontrollable circumstances MIPS eligible clinicians may face as a result of widespread catastrophic events affecting a region or locale in CY 2017, such as Hurricanes Irma, Harvey and Maria.

CMS also adopted a number of policies affecting APM participants.  For instance, the final rule:
Continue Reading CMS Modifies Medicare Physician Quality Payment Program Rules for 2018

CMS has proposed new regulations to continue implementing the “Quality Payment Program” (QPP) — the new Medicare physician fee schedule (MPFS) update framework mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As previously reported, starting in 2017, physicians will be paid under the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM).

For the second year of the QPP, CMS is proposing to continue a number of transition policies established for 2017 while “ramping up to full implementation.” Notably, with regard to the MIPS track, CMS proposes to:
Continue Reading CMS Proposes Changes for Second Year of Medicare Physician Quality Payment Program

CMS expects nearly 100% of eligible clinicians in Advanced Alternative Payment Models (APMs) to meet the Medicare Qualifying APM Participant (QP) standard for performance year 2017 and be eligible to receive a 5% APM incentive payment in 2019 under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules. This projection is based on an