In the last Vetters Enterprises blog, we discussed the Centers for Medicare & Medicaid Services (CMS) changes for 2017 regarding the model by which physicians are reimbursed for care. The Medicare Access & CHIP Reauthorization Act (MACRA) was implemented to streamline reporting of quality care and emphasize consequence for those performing poorly. The main goal is simple – make patients healthier by rewarding high quality care. The Quality Payment Program (QPP) under MACRA that we discussed in our last blog consists of two tracks physicians can choose from: MIPs and APMs. Let’s break down APMs.
Quality Payment Program: What are APMs?
CMS defines Advanced Alternative Payment Models (APMs) as new approaches to paying for medical care through Medicare that incentivize quality and value. The QPP offers additional incentives for Qualifying Professionals (QPs) who participate in APMs. MACRA states that APMs include: CMS Innovation Center model, Medicare Shared Savings Program (MSSP), Demonstration under the Health Care Quality Demonstration Program, and Demonstration required by federal law.
How Do You Qualify for APMs?
Most physicians will be subject to the MIPS track based on eligibility requirements. The following three groups will be excluded from the MIPS track: first year of Medicare Part B participation, certain participants in advanced alternative payment models, and those below the low patient volume threshold – meaning those who provide care for 100 or fewer Medicare patients and whose Medicare billing charges are less than or equal to 10k annually. To qualify as an Advanced APM and be excluded from MIPS, the following criteria (as defined by MACRA) must be met:
- The APM requires at least 50% of the participants are required to use certified EHR technology; after year one, this threshold increases to 75%
- The APM payments are based on quality measures comparable to those in the MIPS Quality of Care performance category
- The APM entities bear more than nominal financial risk for monetary losses OR the APM is a Medical Home Model expanded under CMMI authority
Qualifying APM participants are eligible for a 5% lump sum bonus each year from 2019-2024 if the APM revenue is met, as well as annual updates of .75% after 2026. In layman’s terms, the MIPS track consists of fixed funds, regulations, restrictions, and penalties; whereas the AMP track consists of a significant share of provider revenue, two-sided financial risk, financial incentives, and exemption from MIPS. Want more useful information? Visit our blog again!
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