Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patients’ outcomes. You may earn a 5% Medicare incentive payment during 2019 through 2024 and be exempt from MIPS reporting requirements and payment adjustments if you have sufficient participation in an Advanced APM.
Earning an incentive payment in one year doesn’t guarantee receiving the incentive payment in future years. It is important to understand that the Quality Payment Program doesn’t change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.
Advanced APMs must meet the following requirements:
Note that although no Medical Home Models have been expanded using the CMS Innovation Center authority, CMS applies a different Advanced APM financial risk criterion to Medical Home Models, and MIPS eligible clinicians participating in Medical Home Models automatically receive the full score for the MIPS improvement activities performance category.
The final rule with comment period defined the risk requirement for an Advanced APM to be in terms of either total Medicare expenditures or participating organizations’ Medicare revenue (which may vary). This enhanced flexibility allows for the creation of more Advanced APMs tailored to physicians and other clinicians, such as advanced practice nurses and small practice participation.
To qualify for the 5% APM incentive payment for participating in an Advanced APM during a payment year, you must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through the Advanced APM during the associated performance year.
|Requirements for APM Incentive Payments for Participation in Advanced APMs
(Clinicians must meet payment or patient requirements)
|Performance Year||2017||2018||2019||2020||2021||2022 & beyond|
|% of Medicare Payments through an Advanced APM||25%||25%||50%||50%||75%||75%|
|% of Medicare Patients through an Advanced APM||20%||20%||35%||35%||50%||50%|
What Happens if I Am in an Advanced APM?
For performance years 2017 and 2018, the participation requirements only apply to Medicare payments and patients. Starting in performance year 2019, clinicians may also meet an alternative standard for Advanced APMs that will include non-Medicare payments and patients.
Once you’re in an Advanced APM, you’ll earn the 5% incentive payment in 2019 for Advanced APM participation in 2017 if:
You’ll need to send in the quality data required by your Advanced APM. Your model’s website will tell you how to send in your Advanced APM’s quality data. See initiatives at the https://innovation.cms.gov website to search, and identify available models.
If you leave the Advanced APM during 2017, you should make sure you’ve seen enough patients or received enough payments through an Advanced APM to qualify for the 5% bonus. If you haven’t met these thresholds, you may need to submit MIPS data to avoid a downward payment adjustment.
Look Out for Even More Advanced APM Opportunities
CMS stated its intent to broaden opportunities for clinicians to participate in Advanced APMs by retrofitting existing models to qualify as Advanced APMs and using the CMS Innovation Center to create new models, including those recommended by the Physician-Focused Payment Models Technical Advisory Committee (PTAC).
One opportunity CMS is considering is testing a new ACO (Accountable Care Organization) Track 1+ model that would be a new Advanced APM in 2018 with lower risk levels than currently available to Medicare ACOs. The final rule also eases the risk criteria for Advanced APMs from the proposal, allowing a broader range of future models, including those tailored to small practices or specialties.
For the 2017 performance year however, CMS estimates that approximately 70,000 to 120,000 clinicians will participate in Advanced APMs and qualify for the 5% incentive payment.
To learn more about Advanced APM opportunities in MACRA—and to stay on track for optimum reimbursement with strategies to avoid payment cuts in the coming years—pick up your copy of Guidebook to Medicare Access and CHIP Reauthorization Act of 2015.