Revenue Cycle Management Blog | GroupOne Health Source

Are You Exempt from MIPS? How Advanced APMs Differ From APMs

Written by Jeff Jones, CPHP | June 15, 2016

Some interesting discussions have emerged since the MACRA proposed rule was announced. One that is acquiring a lot of attention is the eligibility requirements of Advanced APM entities. Under the proposed rule only Advanced APMs will qualify for the 5% annual lump sum payment and be exempt from MIPS. In this post we will dive deeper into what it takes to become an Advanced APM and what happens if an APM entity does not qualify as an Advanced APM.

Eligibility Requirements and Exemptions for MIPS

MIPS represents the default track for clinicians under the new Quality Payment Program (QPP). The eligibility net expands from physicians, physician assistants, clinical nurse specialists, and certified nurse anesthetists for Calendar Year (CY) 2017.

Calendar Year 2018 will then include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutrition professionals for CY2019 and onward.

Furthermore, only those clinicians in the categories above who bill for Medicare Part B or Critical Access Hospital (CAH) Method II payments assigned to the CAH are eligible.

Billings for Medicare Part A, Medicare Advantage Part C, Medicare Part D, FQHC or Rural Health Clinic payment methodologies, and CAH Method I payments are all excluded from MIPS eligibility determination.

The exemptions from MIPS for CY2017 are as follows:

  • Clinicians in their first year of Medicare Part B participation
  • Clinicians billing Medicare Part B up to only $10,000 and providing care for up to 100 Part B patients in one year
  • Clinicians participating in an Advanced APM entity, for which either:
    • The collective Part B payments for services delivered by the Advanced APM entity’s clinicians to patients attributed to the entity is at least 20% of the payments for services delivered by the entity’s clinicians to all patients who could, but may not be, attributable to the entity (attribution-eligible).
    • The collective number of patients who receive services delivered by the Advanced APM entity’s clinicians and who are attributed to the Advanced APM entity is at least 10% of the number of all patients who are attribution-eligible and received services delivered by the entity’s clinicians

Inevitably, there are clinicians who not only belong to an Advanced APM or a non-Advanced APM, but are also subject to MIPS.

For example, Advanced APM clinicians not meeting either minimum threshold in the scenarios above are also subject to MIPS. The MACRA proposed rule defines special scoring and data submission rules governing these so called “MIPS APM” clinicians.

A common example of this consists of clinicians who participate in a one-sided Track 1 Medicare Shared Savings Program (MSSP) ACO, which is a non-Advanced APM.

Qualifying Participation Requirements for Advanced APMs

CMS has made it clear that it is not enough for a clinician to just be listed as a participant in an Advanced APM to gain the 5% annual bonus and exemption from MIPS.

CMS will attempt to verify that an Advanced APM’s clinicians collectively deliver a large enough percentage of a particular attributable patient population’s Medicare Part B services via the Advanced APM entity in two ways:

  1. The Payment Amount Method and
  2. The Patient Count Method. CMS has stated they will use both methods and select the result from the method that is most favorable to the clinician in terms of qualifying participation.

The Payment Amount Method takes the sum of collective Part B payments for services delivered by the Advanced APM entity’s clinicians to patients attributed to the entity according to the attribution rules of the Advanced APM program and divides that by the sum of collective Part B payments for services delivered by the entity’s clinicians to all patients who could, but may not be, attributable to the entity.

Qualifying APM Participants

If this threshold is at least 25%, all the clinicians participating in the Advanced APM are deemed “qualifying APM participants” or “QPs”, who would now earn the annual 5% Advanced APM bonus.

Partial Qualifying APM Participants

If the threshold score is at least 20% but less than 25%, then all the clinicians are deemed “partial qualifying APM participants” or “Partial QPs”, who do not earn the annual 5% bonus but have the option to participate in MIPS or not.

Subsequent Performance Years

It should be noted that for subsequent performance years, the above 25% and 20% thresholds will increase.

In addition, for the CY2021+ performance years, participation in “Other Payer Advanced APMs”, which are not for Medicare Part B, can also count towards QP and Partial QP determination for the purpose of the 5% bonus and MIPS exemption.

The Patient Count Method is similar to the Payment Amount Method except that the numbers of attributed and attribution-eligible patients are used instead of the Part B payments, and the 25% and 20% thresholds for QP and Partial QP are replaced by 20% and 10% respectively, for the CY2017 performance year.

Similarly, theses thresholds also escalate for the CY2021+ performance years.

Not an Advanced APM - MIPS APM Scenario

Earlier in the post we noted that some clinicians may be in an Advanced APM but not meet minimum thresholds, which means they would also be subject to MIPS.

Also, some APMs will not qualify as Advanced APMs so those clinicians will also be subject to MIPS.

This is called the “MIPS APM” scenario.

An example of this can be found in the proposed rule, which states that 90% or more of Medicare Shared Savings Program (MSSP) ACOs in the one-sided (incentive only) Track 1 do not qualify as Advanced APMs, but rather as Non-Advanced APMs.

These entities can have MIPS data submission requirements and MIPS category scoring weights differing from those of other MIPS eligible clinicians.

An example of this can also be found in the proposed rule and states that “MIPS APM” clinicians will be scored in the MIPS Quality, Advancing Care Information, and Clinical Practice Improvement Categories. The Resource use category will be set to 0% and those points would be distributed to the other three categories.

Why is the Resource Use Category Set to 0%?

This is because the Resource Use category is already being measured within the MSSP.

Interestingly enough, it is possible for an ACO to earn a shared savings from MSSP, but also be penalized under MIPS, because its MIPS Composite Performance Score did not meet the Performance Threshold.

This however, is still the proposed rule, and is not yet finalized.

It is entirely possible for CMS to qualify some of these APMs as Advanced APMs in order to cut down on the confusion and number of “MIPS APM” scenarios. But inevitably there will be some clinicians who will be subject to both tracks of the Quality Payment Program.

Where can I find more information?

Check out these resources from CMS for more information on MACRA.

Get the latest updates sent to you; join the Quality Payment Program list serv

Questions or Comments About MACRA?

Leave a comment below if you have a question regarding the proposed rule and how it will impact your practice.

We will also be publishing posts regularly to keep you updated on MACRA and providing further details about the Advanced Payment Models (APMs). Subscribe to updates today and receive notifications right to your inbox when these articles are published.


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