As discussed in previous tidbits, ACG members must meet certain criteria before being eligible for the “QPP.”

Your first step: Check eligibility

First you need to find out whether you must participate in the QPP.  Visit the Medicare Quality Payment Program website to check your participation status by entering your national provider identifier (NPI) number.

Your next step (if you must participate): Pick your QPP payment track

Your next step requires you to decide what reimbursement system or “track” you can participate in for your Medicare fee-for-services patients.  This participation look-up will help you. The options:

  1. A modified fee-for-service reimbursement system called the Merit-Based Incentive payment System (MIPS); or
  2. A CMS-approved alternative payment model (APM), like participating in a bundled payment or accountable care organization (ACO) payment model. These CMS-approved payment mechanisms are called “advanced alterative payment models (APMs).”

Track 1 MIPS

What is the “Merit-Based Incentive Payment System (MIPS)”?

  • MIPS consolidates the former Medicare quality reporting programs: PQRS, the Value Modifier and the “Meaningful Use” program into one composite program.
  • MIPS is broken down into 4 performance categories, with different weights for each category.
  • CMS will develop a “composite score,” or total performance score from each category, using a scoring scale of 0 to 100.  This target score will be based upon previous years’ actual composite score data or other quality reporting data if no prior year data exists.
  • This aggregate score from each performance category will be compared to the CMS “target score.”
  • The provider’s reimbursement will be adjusted (bonus, cut, or no update) on a sliding scale based on a comparison of all other providers’ scores (remember the 2-year lag).
  • The provider still submits Medicare fee-for-service claims but reports other information as well.

What are the MIPS performance categories and weights for CY 2019?

Track 2 Alternative Payment Models (APMs)

What’s the difference between an “Advanced Alternative Payment Model” vs. an “Alternative Payment Model”?

MACRA does not create new alternative payment models, such as accountable care organizations or bundled payments.  MACRA does, however, authorize incentives to encourage participation.

Unlike MIPS, participants of any APM submit data to the APM entity, and not CMS.  The APM entity then aggregates this data and submits to CMS.

In short, Advanced APMs are a subset of APMs.  They are approved APMs that CMS has labeled “Advanced APMs.”  Advanced APM entities must meet certain requirements outlined in MACRA and subsequent QPP regulations to be eligible for financial incentives.  Participants in Advanced APMs become a “qualified participant,” or a “QP,” by joining these Advanced APM entities and meeting certain requirements.  The biggest difference is that you are also excluded from the MIPS if you are in an Advanced APM.  Some other perks:

  • For payment years from 2019 through 2024, QPs receive a lump sum incentive payment equal to 5% of their prior year’s payments for Medicare Part B covered professional services.
  • For 2026 and future years, QPs receive a higher Medicare fee schedule annual update (0.75%) under the Medicare physician fee schedule versus non-QPs (0.25%).
  • For payment years 2021 and later, eligible clinicians may become QPs through a combination of participation in Advanced APMs and Other Payer Advanced APMs (i.e., the “All-Payer Combination Option”).

You do have the opportunity to participate in an APM that is not considered an “Advanced APM.”  If so, you would be required to participate in MIPS; however, there is a different scoring standard.  Also, CMS also allows for “Partial QPs,” who can choose whether they wish to be subject to a MIPS payment adjustment.

What is an example of an Advanced APM?

Below is the list of payment models that would be considered an “Advanced APM” in 2019 (list tailored for GI; there are others):

  • Bundled Payments for Care Improvement (BPCI) Advanced)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program/ACOs – Track 2
  • Medicare Shared Savings Program/ACOs – Track 3
  • Next Generation ACO Model

Each of these models have different rules but share the same basic theme: the participants share both the responsibility and risk in providing care to meet certain quality and financial benchmark targets.

ACG’s goal is to provide membership with educational guidance in a simple, easy-to-understand fashion.  We compiled a detailed overview for you that seeks to make some sense out of this alphabet soup, including acronyms such as MACRA, QPP, MIPS, APMs, etc. – but hopefully in a simplified fashion and in plain English.

Click here to check out our review of Year 3!