Understanding Basics Of Alternative Payment Models (APMs)

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Understanding Basics Of Alternative Payment
Models (APMs)
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Understanding Basics Of Alternative Payment
Models (APMs)
An Alternative Payment Model (APM) is a payment
approach that gives added incentive payments to
provide high-quality and cost-efficient care. In
October 2021, the Center for Medicare and
Medicaid Innovation (CMMI) announced a goal of
having every Medicare beneficiary and the
majority of Medicaid beneficiaries covered by
some type of alternative payment model (APM) by
2030. CMMI considers APMs to be any arrangements
whereby providers are held accountable for the
quality and costs of care, not just paid based on
the volume of services they deliver. Many states
have been experimenting with Medicaid alternative
payment models (APMs) to try to control spending,
improve care, and increase accountability within
Medicaid and across the health care system. Many
states are taking advantage of Medicaid program
flexibility and federal financing to implement
APMs in a variety of ways. Although many state
initiatives are underway, relatively few have
been evaluated for their impact on total cost of
care of health outcomes. The potential impact of
Medicaid alternative payment models on care
delivery can depend considerably on how much of a
providers revenue comes from Medicaid. Types of
Alternative Payment Models MIPS APMs MIPS APMs
have MIPS eligible clinicians participating in
the APM on their CMS-approved participation list.
MIPS APMs are APMs that meet following criteria
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Understanding Basics Of Alternative Payment
Models (APMs)

• APM entities that participate in the APM under an
  agreement with CMS
• APM bases payment incentives on performance
  (either at the APM entity or eligible clinician
  level), on cost/utilization, and quality
  measures.
• Advanced APMs
• Advanced Alternative Payment Models (APMs) are a
  track of the Quality Payment Program that offer a
  5 percent incentive payment for achieving
  threshold levels of payments or patients through
  Advanced APMs. If you achieve these thresholds,
  you become a Qualifying APM Participant (QP) and
  you are excluded from the MIPS reporting
  requirements and payment adjustment. Advanced
  APMs allow eligible clinicians to become a QP for
  an opportunity to receive a 5 percent APM
  incentive payment and to be excluded from MIPS.
  Advanced APMs are APMs that meet following 3
  criteria
• Requires participants to use certified EHR
  technology
• Provides payment for covered professional
  services based on quality measures comparable to
  those used in the MIPS quality performance
  category and
• Either (1) is a Medical Home Model expanded
  under CMS Innovation Center authority OR (2)
  requires participants to bear a significant
  financial risk.

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Understanding Basics Of Alternative Payment
Models (APMs)
Advanced MIPS APMs Most Advanced APMs are also
MIPS APMs. MIPS Eligible clinicians participating
in Advanced APMs are included in MIPS if they do
not meet the threshold for payments or patients
sufficient to become a Qualifying APM Participant
(QP). The MIPS eligible clinician will be scored
under MIPS according to the APM scoring
standard. All-Payer Advanced Alternative Payment
Models During the 2022 QP Performance Period,
eligible clinicians will be able to become
Qualifying Alternative Payment Model Participant
(QPs) through the All-Payer Combination Option.
In order to do so, a clinician must be in a
Medicare Advanced APM. A clinician can also
combine their participation with an Other-Payer
Advanced APM. Eligible clinicians who are
determined to be QPs will receive a 5 percent APM
incentive payment in the payment year and will
not be subject to the MIPS reporting requirements
or payment adjustments. Incentives for Medicaid
clinicians who also treat Medicare patients MACRA
established the QPP, which offers financial
incentives for Medicare Part B providers to
participate in risk-bearing APM arrangements.
Under MACRA, qualifying APM participants (QPs)
who earn a minimum percentage of their payments
through advanced alternative payment models or
see a minimum percentage of patients through
advanced APMs are exempted from merit-based
incentive payment system (MIPS) reporting
requirements and can earn a five percent Medicare
payment bonus from 2019-2024.
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Understanding Basics Of Alternative Payment
Models (APMs)
Beginning in 2026, QPs will receive a higher
annual Medicare fee schedule adjustment than
non-QPs. In addition, eligible clinicians who
participate in certain APMs but dont meet the QP
requirements may still receive more favorable
scoring under MIPS. We shared basics of
Alternative Payment Models (APMs) for reference
purpose only, for detailed understanding you
visit CMS website mentioned below. Medisys Data
Solutions is a leading medical billing company
providing billing and coding services for various
medical billing specialities. If you need any
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contact us at info_at_medisysdata.com/ 302-261-9187
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