Eligibility
MIPS APMs are those APMs that meet these three criteria:
- The practice participates in the APM under an agreement with CMS;
- The APM requires that practice include at least one MIPS clinician on a Participation List; and
- The APM bases payment incentives on performance (either at the group or clinician level) on cost/utilization and quality measures.
A practice must be actively participating in a MIPS APM on at least one of three “snapshot” dates: March 31, June 30 or August 31. If a practice participates in a MIPS APM but aren’t on the APM Participation List on one of the three snapshot dates, the practice won’t be scored using the APM scoring standard and should instead report to MIPS according to the generally applicable MIPS requirements, either as an individual or as a group.
For MSSP, all MIPS-eligible clinicians who bill through the Tax Identification Number (TIN) of an ACO participant are participating in the ACO (the ACO = the APM Entity). However, a clinician must be listed as part of the APM Entity as of December 31 of the performance year in order to be counted as participating in the ACO for the purposes of the MIPS APM Scoring Standard. For the 2019 payment year, CMS will look to 2017 performance.
Scoring Standard
Like MIPS, clinicians in a MIPS APM will receive a score between 0-100 based on performance in the MIPS performance categories (Quality, Improvement Activities, Promoting Interoperability and Cost). If the clinician scores above the threshold for a given year, a bonus will be provided. A penalty will be applied if the score is below the threshold. Scores at the performance threshold receive a neutral payment.
While the requirements might be very similar to MIPS, the weights assigned to each category under the APM scoring standard might differ from the regular MIPS performance category weights.
The APM scoring standard is designed to account for activities already required by the APM. For example, the APM scoring standard eliminates the need for MIPS clinicians to duplicate submission of Quality and Improvement Activity performance category data and allows them to focus instead on the goals of the APM.
MIPS APM and ACO models
Each MIPS APM or ACO model will have minor differences. It is important for practices to confirm the model type to understand the requirements.
Some of the models are listed below:
Medicare Shared Savings Program (MSSP) - The Shared Savings Program offers different participation options (tracks) that allow ACOs to assume various levels of risk.Starting in 2019, the options are listed under BASIC and Enhanced tracks.
Next Generation Accountable Care Organization - NextGen ACO - The Next Gen ACO model allows ACOs to assume higher levels of financial risk and reward than under the traditional Medicare Shared Savings Program (MSSP) Tracks.
Oncology Care Model - one-sided risk (OCM) - The OCM is a 5-year model focused on increasing the coordination of oncology care through financial and performance accountability for chemotherapy episodes of care. Radiation oncologists within the OCM must still collect data on their patients regardless of whether they fall into the OCM episode. The radiation data will still be submitted through the OCM by the groups administrator along with the OCM data. There is also a two-sided risk model that is considered an Advanced APM.