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. APMs can apply to a specific clinical condition, a care episode, or a population. 

Advanced APMs
In the Advanced APM track of the Quality Payment Program (QPP), you may earn a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment.

Advanced & MIPS APMs

MIPS APMs are APMs that meet these 3 criteria:

  • APM entities that participate in the APM under an agreement with CMS
  • APM entities that include 1 or more MIPS eligible clinicians on a Participation List
  • APM bases payment incentives on performance (either at the APM entity or eligible clinician level), on cost/utilization, and quality measures

Most Advanced APMs are also MIPS APMs. If an eligible clinician (EC) participating in the Advanced APM does not meet the threshold for sufficient payments or patients to become a Qualifying APM Participant (QP), they will be scored under MIPS according to the APM scoring standard.

All-Payer/Other-Payer Option
ECs can become QPs through the All-Payer Option. To exercise this option, ECs must participate in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs. Other-Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs under Medicare.

Information for Advanced APMs and MIPS APMs may change each Performance Year (PY).

For More Information and Additional Resources, Visit the CMS QPP Resource Library

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