Qualifying APM Participants (QPs) are clinicians who have a certain % of Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity.
Step 1 - Qualifying APM Participant determinations are made at the Advanced APM Entity level, with certain exceptions:
Step 2 - CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods (payment amount and patient count).
Step 3 - The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.
Step 4 - All the eligible clinicians in the Advanced APM Entity become QPs for the payment year.
CMS will make QP determinations 3 times during the performance period.
QPs will be identified on the following schedule: March 31 of the performance period; June 30 of the performance period; and August 31 of the performance period. To be included in the QP calculations, an EC must be on the AAPM’s participation list during at least one of these determination snapshots.
Once determined to be a QP, an EC will retain QP status for the performance period even if he or she is not included in the AAPM’s participation list during all determination snapshots.
For example, an EC included on the participation list and determined to be a QP during the March 31 snapshot, but not included on the participation list during the June 30 snapshot will be considered a QP for the performance period.
MACRA defines any of the following as a qualifying Alternative Payment Model (APM):
If you receive 25% of Medicare payments or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% incentive payment in 2019.
Advanced APMs which 1) requires participants to use certified electronic health records (EHR) technology, 2) bases payments on quality measures, and 3) involves a certain level of financial risk.
Physicians participating in Advanced APMs that meet qualified participation levels are exempt from MIPS, receive a 5% annual bonus payment for 6 years, and will receive a higher fee schedule update for 2026 and beyond. For the first year of the program in 2017, the Centers for Medicare & Medicaid Services (CMS) has indicated the following models would qualify as Advanced APMs.
In 2017, the following models are Advanced APMs:
Yes, at least 50% of the clinicians in each APM Entity must use certified EHR technology to document and communicate clinical care information with patients and other health care professionals.
For both 2017 and 2018, an Advanced APM must require at least 50 percent of eligible clinicians (or each hospital if hospitals are the APM participants) to use CEHRT to document and communicate clinical care with patients and other health care professionals. That is, the APM must require the use of CEHRT in its terms and conditions, or other legal vehicle through which APM Entities are held accountable; this test is not applied at the APM entity or QP level. CMS will wait for more information on how this threshold would impact specific APMs, such as specialty APMs, before increasing the threshold, if at all.
An MSSP ACO meets the criterion if it holds APM Entities accountable for their eligible clinicians’ use of CEHRT by applying a financial penalty or reward based on the degree of CEHRT use.
By 2018, certification must meet the new 2015 Edition Health IT Certification Criteria (2015 Edition) finalized in late 2015.
CMS has established an additional category of APMs that do not meet the criteria for Advanced APMs. For example, Track 1 ACOs in the Medicare Shared Savings Program do not meet the requirements for "more than nominal" financial risk that CMS has established for Advanced APMs, so physicians participating in Track 1 ACOs would be participants in a MIPS APM.
For the 2017 performance period, MIPS APMs include:
Under the APM scoring standard, ECs are subject to the MIPS reporting requirements and payment adjustments. To ease the reporting burden for the quality performance category, CMS will use the APM quality data submitted on behalf of the participating MIPS ECs. The cost performance category is scored at 0% for MIPS APM participants. CMS will assign each MIPS APM an IA score based on the APM model design and how it compares with the IAs available.