Alternative Payment Model (APM)

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What is MACRA?

The Medicare Access & CHIP Reauthorization Act (MACRA) repealed the Medicare Sustainable Growth Rate (SGR) and replaces it with a new Quality Payment Program (QPP). Participating clinicians will be subject to payment adjustments based on their performance.

Reporting Pathways

Clinicians will follow either the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM) track, depending on current reimbursement. Eligible clinicians will follow the MIPS path, unless they are in an Alternative Payment Model. CMS has stated that they expect about 90% of clinicians to participate in MIPS.

Alternative Payment Model (APM)

Participating in a qualifying APM can award the clinician a 5% bonus payment from 2019-2024. Clinicians are part of an APM when either of the following conditions are met:

  • 25% of Medicare payments are through an APM in 2017
  • 20% of Medicare patients are through an APM in 2017

Clinicians are considered APM MIPS when they are not part of an Advanced APM.

Merit-based Incentive Payment System (MIPS)

The MIPS track combines three current Medicare programs (Meaningful Use, PQRS, & VBM) and adds an additional category. By 2020, clinicians will see payment adjustments from -9% to +27% based on a composite MIPS score from the four performance categories. Scores for each of the four categories are weighted based on a 1 to 100-point scale.

  • Advancing Care Information (ACI) formerly Meaningful Use (MU)
  • Quality Measures formerly known as Physician Quality Report System (PQRS)
  • Resource Use (Cost) formerly known as Value Based Modifier (VBM)
  • Clinical Practice Improvement Activities (CPIA)

The maximum negative and positive adjustments increase each reporting year.

Advanced Alternative Payment Model (APM)

#1

The APM must require participants to use 2014 CEHRT version in 2017.

#2

The APM must provide payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS.

#3

The APM must either require that participating APM Entities bear risk for monetary losses of more than nominal amount under the APM, or be a Medical Home Model.

The following models are considered an Advanced APM for 2017:

  • Comprehensive ESRD Care (CEC)
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program - Track 2 (MSSP)
  • Shared Savings Program - Track 3 (MSSP)
  • Oncology Care Model (OCM)
  • Comprehensive Care for Joint Replacement
  • Vermont Medicare ACO Initiative

CMS will continue to determine Advanced APM’s on a quarterly basis to add or remove models.

APM MIPS

Clinicians in an Advanced APM who do not meet the scoring threshold or clinicians in other APMs will follow the APM MIPS route. Preferential scoring will be given to these participants under MIPS scoring standard.

Improvement Activities

  • APM MIPS participants start with 50% credit in this category since being a part of an APM demonstrates improvement activities.
  • Some APM models may receive full credit such as PCMH.
  • APM MIPS clinicians cannot receive the annual Advanced APM 5% lump-sum bonus payment. However, they may qualify for positive MIPS payment adjustments and exceptional performance adjustments, based on the final score.

Scoring standards vary depending on the participant’s APM model.

Technical Requirements

Successful MACRA reporting requires the following:

  • NextGen Regulatory Release (version 5.9/KBM 8.4). The application and KBM upgrade are performed at the same time.
    • Advanced APM must upgrade by January 1, 2018
    • APM MIPS must upgrade by October 1, 2018 but recommend to upgrade in early 2018 *
  • NextGen Patient Portal or a patient portal solution
  • NextGen Share
  • NextGen HQM
  • NextGen Care or another population health solution is recommended

Getting Started

Here are your first steps to planning your MACRA transition:

  • Determine your MACRA path: MIPS, APM MIPS, or Advanced APM;
  • Develop a MACRA roadmap and timeline for the next two years;
  • Work on getting organizational buy-in;
  • Create an upgrade budget and allocate resources;
  • Review the TempDev MIPS Toolkit;
  • Contact us to plan your successful MACRA transition.

MACRA: APM – Top 10 Things to Know

  • 01
    How do I know if I am an Advanced APM?
    The following models are considered an Advanced APM:
    • Comprehensive ESRD Care (CEC)
    • Comprehensive Primary Care Plus (CPC+)
    • Next Generation ACO Model
    • Shared Savings Program (MSSP) - Track 2
    • Shared Savings Program (MSSP) - Track 3
    • Oncology Care Model (OCM)
    • Comprehensive Care for Joint Replacement
    • Vermont Medicare ACO Initiative
    APM participants that are not qualified providers will receive favorable scoring under MIPS
  • 02
    What if I'm part of an APM that is not a Qualified Advanced APM for 2017?
    You are considered APM MIPS and you will still submit your data to the APM prior to the March 31, 2018 deadline.
  • 03
    How do I report under Advanced APM?
    You must report through your APM if 25% of your Medicare payments or 20% of your Medicare patients are through an Advanced APM in 2017.
  • 04
    What if some of my practices participate in an APM and others do not?
    APM qualified groups will follow the APM track and the non-qualified will follow the MIPS track. Your group will still need to be upgraded by January 1, 2018 for the APM providers.
  • 05
    What if I participate in Medicare Advantage?
    Participation for the 2019 performance period may be included when determining whether eligible clinicians earn the 5% incentive payment and are exempt from MIPS.
  • 06
    How do I ensure I'm ready for 2017?
    Verify your APM is a qualified APM and that you are receiving the required percentage of your patients and payments through your APM.
  • 07
    What can I do now to be prepared?
    • Budget and plan for a new version and KBM upgrade in late 2017 (Advanced APM) or early 2018 (APM MIPS)
    • You will need NextGen HQM, a patient portal solution, and NextGen Share.
  • 08
    Which version of NextGen is required?
    • 2017 - Use 2014 CEHRT NextGen version 5.8/KBM 8.3 or higher
    • 2018 - Use the 2015 CEHRT NextGen Regulatory Release (version 5.9/KBM 8.4) which requires a version and KBM upgrade at the same time
  • 09
    How will I report to my APM?
    You will report your data to your APM who will then report the data to CMS.
  • 10
    How can I use TempDev to increase my likelihood of success?
    TempDev can work with you to help you build your MACRA Roadmap, provide strategic planning, project management, training, go-live support, and development support.
  • #1
    Am I Advanced APM?
  • #2
    Not a qualified Advanced APM?
  • #3
    Advanced APM reporting?
  • #4
    Mixed APM & MIPS?
  • #5
    What about Medicare Advantage?
  • #6
    Ready for 2017?
  • #7
    What can I do now?
  • #8
    What version of NextGen?
  • #9
    How will I report?
  • #10
    How can TempDev help?
  • #1
    Am I Advanced APM?
  • #2
    Not a qualified Advanced APM?
  • #3
    Advanced APM reporting?
  • #4
    Mixed APM & MIPS?
  • #5
    What about Medicare Advantage?
  • #6
    Ready for 2017?
  • #7
    What can I do now?
  • #8
    What version of NextGen?
  • #9
    How will I report?
  • #10
    How can TempDev help?
#1
Am I Advanced APM?
#2
Not a qualified Advanced APM?
#3
Advanced APM reporting?
#4
Mixed APM & MIPS?
#5
What about Medicare Advantage?
#6
Ready for 2017?
#7
What can I do now?
#8
What version of NextGen?
#9
How will I report?
#10
How can TempDev help?

Roadmap for MACRA: APM

TempDev will help guide you through this journey

January 1, 2017

MACRA 2017 reporting period begins

September 2017

NextGen Regulatory Release is available

October 1, 2017

Last day to begin 2017 reporting period for APM MIPS.

January 1, 2018

MACRA 2018 reporting period begins
Upgrade to NextGen Regulatory Release
• Advanced APM: Required
• APM MIPS: Recommended

March 31, 2018

Deadline for 2017 submission

October 1, 2018

Last day to begin 2018 reporting period
Upgrade to NextGen Regulatory Release is required

March 31, 2019

Deadline for 2018 submission

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Learn About MACRA: MIPS

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Learn about the MIPS reporting path.

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