Background on APMs

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

  • Medicare Shared Savings Program (MSSP) Track 1
    • MSSP Track 1 participants are still subject to MIPS reporting, but the weighting of each measure category is different than the standard MIPS reporting
      • Quality: becomes 50% of their score
        • The group’s GPRO submission will satisfy this category
      • Cost: 0%
      • Improvement Activities: 20%
        • CMS is providing full credit for this category for being part of an ACO
      • Promoting Interoperability: 30%
        • MSSP Track 1 Providers are wise to submit PI data to increase the opportunity to earn an exceptional bonus
  • Next Generation (Next Gen) ACO Models
    • Next Generation ACOs are both Advanced APMs and MIPS APMs. As with all Advanced APMs, eligible clinicians that are part of a Next Generation ACO model will be assessed for Qualified Participant (QP) status. If the eligible clinicians within the APM entity (ACO) collectively meet the thresholds to become a QP, they will be excluded from MIPS reporting and will earn an 8% APM Incentive Payment in 2018.
    • If a provider does not meet the threshold to become a QP and is determined to be a partial QP, their APM Entity may choose to participate in MIPS for the 2019 payment year. If the APM Entity reports to MIPS, the partial QP will receive special scoring under the APM Scoring Standard and be subject to the MIPS payment adjustment.
    • If a provider is not a QP or Partial QP, they will receive special scoring under the APM Scoring Standard and be subject to the MIPS payment adjustment.
  • Advanced APMs
    • A subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.
    • Providers may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM.

Advanced APM models

Advanced APMs exclude a physician from MIPS, and create an opportunity for a lump sum payment from Medicare of 5% of last year’s fee for service payments. To qualify as an alternative payment model under the MACRA statute, the organization must use Certified EHR Technology, report quality measures comparable to measures under MIPS, and bear financial risk in excess of a nominal amount.

The following links provide access to additional information on each of the Advanced APMs available:

If you would like to check your Advanced APM participation status, refer to this link to CMS’s Qualifying APM Participant Look-up Tool.

Payment incentive requirements for providers in an Advanced APM

Providers that are part of an Advanced APM will earn a 5% incentive payment in 2019 for participation in 2017, and an 8% incentive payment in 2020 for participation in 2018, if:

  • They receive 25% of their Medicare Part B payments through an Advanced APM or
  • See 20% of their Medicare patients through an Advanced APM

Providers will need to submit the quality data required by their Advanced APM; the web sites for each of the models listed above provide instructions on how to send Advanced APM quality data.

If a provider within an Advanced APM does not meet the criteria listed above, they have two options:

  1. Submit data in accordance with the MIPS submission criteria, creating the opportunity to earn a payment incentive, remain neutral, or incur a penalty
  2. Do nothing and maintain the same payment level as 2018, incurring no penalty nor incentive