MIPS APMs May Catch Many Practices Off Guard

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MIPS APMs May Catch Many Practices Off Guard

Category : Uncategorized

Author: Michael Marron-Stearns, MD, CPC, CFPC (Michael@ApolloHIT.com)

This article discusses how a large percentage of clinicians eligible for MIPS will receive MIPS Scores in 2017 and 2018 based on what are called “MIPS APMs” that use a distinctly different scoring methodology than the MIPS, referred to as the APM Scoring Standard.  This article discusses the implications of being in a MIPS APM on your final MIPS score and importantly your reporting obligations.

Any clinician that meets the following three criteria will have their MIPS score determined by the MIPS APM scoring methodology. This includes clinicians that meet the following criteria:

  1. MIPS eligible,
  2. Participating in a CMS approved Alternative Payment Model (APM), and
  3. The clinician does not meet the requirements to be a Qualifying Participant in an Advanced APM. In other words, clinicians that fall short of the minimum reimbursement or patient volume thresholds will automatically be scored using the MIPS APM scoring standard methodology. Clinicians that meet what is referred to as the Partially Qualifying Participant thresholds are given the option of participating in a MIPS APM. They do not have the option of having their MIPS score determined using the “traditional“ MIPS scoring methodology.

Why is this important?

For example, all clinicians that participate in Alternative Payment Models such as a Medicare Shared Savings Program (MSSP) Accountable Care Organization-Track 1 will have their MIPS score determined by the MIPS APM scoring standard.  This is anticipated to affect a large number of clinicians in 2017 and 2018.  These practices do not need to independently report any MIPS data other than their use of electronic health records through the Advancing Care Information performance category of MIPS.

All participants in a MIPS APM entity, such as a Track 1 MSSP ACO, will receive the same MIPS score. This score will:

  1. Be used to determine Part B Medicare payments to the individual clinicians in the corresponding payment year (e.g., 2019 based on 2017 performance), and
  2. It will be publicly displayed on the Medicare Physician Compare website.

MIPS Scores using the APM Scoring Standard are Determined Using Two Different Methods in 2017

The APM scoring standard that is used depends on the type of APM entity. There are two general categories. The first method applies to MIPS eligible clinicians participating in Medicare Shared Savings Program (MSSP) ACOs, including all Track 1 participants and those participating in Track 2 and Track 3 ACO’s that do not meet the requirements to be Qualifying Participants in and Advanced APM.

In this type of MIPS APM the performance categories have the following weightings:

  • Quality: 50%
  • ACI: 30%
  • Improvement Activities: 20%
  • Cost: 0%

As noted above, individual practices have no reporting requirement for quality measures, this is the responsibility of the ACO.  However, they do need to independently report their ACI performance scores.

In this type of MIPS APM, i.e. MSSP ACO’s, the average ACI performance score from each participant in the ACO is averaged together to determine the ACI score for the entire MIPS APM entity.

In general, CMS will credit the MIPS APM entity with the full 20 points from the improvement activity category.  There is no reporting requirement at the practice level.

Alternative Payment Models that are not MSSP ACO’s use different scoring metrics. In the 2017 performance year quality will not be used to determine the MIPS score for these entities. Non-ACO APMs include the Oncology Care Model, the End Stage Renal Disease Care Model, Comprehensive Primary Care +, and the Next Generation ACO Model.

For example, clinicians that participate in one of these APMs in the qualify to be in a MIPS APM entity will have their score based on the following weightings in 2017:

  • Advancing Care Information: 75%
  • Improvement Activities: 25%
  • Quality: 0%
  • Cost: 0%

This places a significant burden on practices to have high performance on Advancing Care Information performance measures. The Advancing Care Information score is determined by a base score and a performance score, each valued at 50% of the total ACI score. Achieving the base score is relatively straightforward, however achieving high scores for the ACI performance measures is somewhat more difficult.

Fortunately, under these types of MIPS APM entities (i.e. non-Track 1-3 MSSP ACOs) only the highest score from each practice, represented by a TIN, in the APM is used to determine the overall ACI score for the MIPS APM entity. CMS will take the highest ACI score from each clinician in an individual practice, combine them with the highest scores from all practices within the MIPS APM entity and then determine an average score. This combined score will be used to determine the final MIPS score.

For example, if the combined highest ACI scores from all the practices in the MIPS APM entity averaged out to 65%, the MIPS APM entity would receive 48.75 MIPS points out of a possible 75. The entity would automatically get credit for improvement activities so 25 points would be added to the score. This would result in a total MIPS score of 73.7 points.  This final MIPS score will be applied to all clinicians participating in the MIPS APM entity.

Based on projections, this would qualify the practice for a small positive payment adjustment of approximately 1 to 2%. This would be applied to all Part B Medicare claim reimbursement in the 2019 calendar year.

MIPS APMs are one of the more challenging areas of the MACRA legislation and subsequent CMS guidance to interpret.  We are available to help you navigate through MACRA.  For additional information and support please contact us at info@apollohit.com .


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