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Alternative Payment Models

Alternative Payment Models

Alternative Payment Models (APMs) are a form of payment reform that incorporate quality and total cost of care into reimbursement rather than a traditional fee-for-service structure. Eligible clinicians (ECs) that participate in a CMS-defined Advanced APM may be exempted from the Merit-based Incentive Payment System (MIPS) program.

APM Image

Academy Comments on MIPS and APM Final Rule
On December 19, the Academy submitted comments to Centers for Medicare & Medicaid Services (CMS) in response to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Final Rule. The Academy commented on the reduced reporting requirements for the transition year; MIPS performance category criteria and scoring; Qualified Clinical Data Registry (QCDR) and quality measure reporting requirements; and applicability of APMs to Otolaryngologists - Head and Neck Surgeons. Access the comments

Just Released: Academy Factsheets on the New MIPS and APM Programs 
To assist Members with MIPS and APM reporting, the Academy has created fact sheets providing an overview of each program including MIPS reporting categories and Advanced APM eligibility criteria. 

Payment Update Table
Annual Payment
Update
Payment
Incentive
2019
0.5%+ 5%
2020
0%+ 5%
2021
0%+ 5%
2022
0%+ 5%
2023
0%+ 5%
2024
0%+ 5%
2025
0%0
2026+
0.75%0

Physician-Focused Payment Model Technical Advisory Committee (PTAC)

PTAC was created by MACRA to submit recommendations for physician-focused payment models to the Secretary of the Department of Health and Human Services (HHS). Learn more here

APM Background

  • Advanced APMs
    • A physician may or may not qualify for the APM payment track by participating in one or more Advanced APM(s) that meet the CMS-defined Advanced APM criteria.
    • Advanced APMs are required to meet the following criteria: a) requires participants to use certified EHR technology; b) base payment provided for covered professional services on quality measures that are comparable to the MIPS quality performance category measures; and c) be either an expanded Medical Home Model or bear more than a nominal amount of risk for monetary losses.
    • Due to the strict eligibility criteria for Advanced APMs, the Academy expects Otolaryngologist - Head and Neck Surgeon participation in Advanced APMs to be low.
    • Eligible Alternative Payment Entity: An entity that: a) participates in an APM with quality measures that are similar to those required by MIPS and requires certified EHR technology use by all participants; and b) takes on at least more than nominal financial risk or is a CMS Innovation Center expanded medical home.
  • MIPS APMs: Some ECs may receive bonus point and alternative scoring criteria for the MIPS program by participating in a MIPS APM.
    • MIPS APMs are either:
      • Advanced APMs in instances where the EC participates in, but does not meet the minimum percentage of patients or payments through through that APM to qualify as as a Qualifying APM participant; or
      • APMs that do not qualify as Advanced APMs, but fall into one of the following categories: a) CMMI models under section 1115A (not a Health Care Innovation Awards); b) Medicare Shared Savings Programs; c) demonstrations under the Health Care Quality Demonstration Program; or d) demonstrations as required by Federal law.
  • Qualifying APM participant (QP): Meets the minimum percentage of patients or payments through an Advanced APM:
    • 2019-2020: 25% of patients or payments
    • 2021-2022: 50% of patients or payments
    • 2023+: 75% of patients or payments
  • Physician-Focused Payment Model Technical Advisory Committee (PTAC): The creation of the PTAC was legislated by MACRA to submit recommendations for physician-focused payment models to the Secretary of the Department of Health and Human Services (HHS). Learn more about PTAC.
  • APMs: The term "alternative payment model" can be attributed to any payment model used by a payer that includes positive or negative payment adjustments that are determined by a physician's performance on quality measures across an episode of care, an episode group, a patient group, or the physician's entire patient population.