Under CMS’s new Quality Payment Program, which will adjust Medicare Part B payments starting in 2019 based on data from this year, physicians and other eligible clinicians must qualify for one of two payment “tracks”, either the Merit-Based Incentive System (MIPS) or the Advanced Alternative Payment Model (Advanced APM) track. A physician who qualifies under the MIPS in 2017 can earn up to a 4% payment adjustment to Medicare Part B payments in 2019. Physicians who qualify under the Advanced APM track can earn up to a 5% payment adjustment in 2019.
Since the Quality Payment Program went into effect on January 1, 2017, it has been unclear whether physicians participating in an Advanced APM in 2017 would be able to meet CMS’ quality and reporting requirements and earn a 5% payment adjustment to their Medicare Part B claims in 2019.
CMS recently provided clarity on this issue by predicting that almost 100% of physicians and other eligible clinicians participating in Advanced APMs in 2017 will qualify for a 5% payment adjustment to their Medicare Part B claims in 2019. CMS based this prediction on an analysis of Advanced APM claims data submitted from January through August 2016 (before the Quality Payment Program went into effect).
CMS also stated that physicians who participate in an Advanced APM need to meet only one of two criteria to earn the 5% payment adjustment in 2019: (1) receive 25% of the physician’s Medicare Part B payments through the Advanced APM; or (2) see 20% of the physician’s Medicare patients through the Advanced APM. [A list of Advanced APMs in which a physician may participate in 2017 can be found at the following link: CMS List of Advanced APMs]
Participating in an Advanced APM can have several benefits (including being exempt from reporting quality data under the MIPS payment track), but also involves taking on some risk. If you are considering participation in an Advanced APM, please contact an experienced attorney to discuss.
CMS is expected to issue formal determinations regarding the qualification of particular physicians for the Advanced APM track later this year.