Merit-based Incentive Payment System (MIPS) APM
Participation in an APM does not, in and of itself, ensure that a clinician is considered a QP or is exempt from MIPS or eligible for other payment incentives. Certain APMs are considered MIPS APMs and their participants may be required to participate in MIPS while also being eligible for certain scoring benefits to recognize their efforts through the APM and avoid duplicative accountability. For example, when a MIPS APM participant reports under traditional MIPS (at any level, including the APM Entity level) they will automatically receive 50 percent credit for the Improvement Activities performance category. To be considered a MIPS APM, participating entities must maintain a participation list of MIPS-eligible clinicians, base payment incentives on clinicians’ performance with respect to cost and quality measures, and maintain a participation agreement with CMS or otherwise to be approved as a model by law or regulation.
Advanced APM
MACRA created incentives for participation in certain more robust APMs that require participating entities to accept more financial risk, use certified electronic health record (EHR) technology (CEHRT), and adjust payment based on quality measures equivalent to those in MIPS. CMS created the designation of Advanced APMs, which are essentially a subset of APMs that have been certified by CMS to meet these three requirements. Only clinicians in Advanced APMs may become a QP, which ensures they are exempt from MIPS and eligible for financial incentives such as a higher conversion factor update. To become a QP in 2025, eligible clinicians must receive at least 75 percent on Medicare Part B payments or see at least 50 percent of Medicare patients through an Advanced APM Entity during the QP Performance Period (January 1–August 31), which represents an increase from last year.
**While one of the goals of the QPP is to transition clinicians and practices into APMs and CMS offers a number of APMs, many of the available models do not recognize the importance of surgeon leadership and the team-based nature of surgical care.
All-Payer/Other Payer APM Option
Eligible clinicians may also become QPs through the All-Payer Combination Option. In order to do so, a clinician must be in a Medicare Advanced APM but can combine their participation with an Other-Payer Advanced APM to meet the QP criteria.
Other-payer Advanced APMs are non-Medicare Fee for Service (FFS) payment arrangements with other payers, such as Medicaid, Medicare Health Plans – including Medicare Advantage, Medicare-Medicaid Plans, 1876 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans –payers with payment arrangements in Aligned Other Payer Models, and other commercial and private payer arrangements categories. They must also meet the following Other-Payer Advanced APM criteria:
- The other payer payment arrangement requires at least 75 percent of Eligible Clinicians in each participating APM entity group to use CEHRT to document and communicate clinical care information.
- Payments for covered professional services must be made based on quality measures that are comparable to the MIPS Quality performance category. There must be evidence-based, reliable, and valid quality measures, with at least one outcome measure if available on the MIPS measure list.
- Participants must bear a certain amount of financial risk. A payment arrangement meets the financial risk requirement if actual expenditures exceed expected aggregate expenditures, or if the payment arrangement is a Medicaid Medical Home Model that meets criteria comparable to Medical Home Model that has been expanded.
Learn more information about these options.
