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Alternative Payment Model

Your guide about the Medicare Advanced Alternative Payment Models (APMs)

APM - the Fundamentals

The Alternative Payment Model (APM) approach rewards providers for delivering cost-effective and high-quality care. Advanced APMs, also one of the two payment paths, happens to be the subset of APMs that allows practices obtain increased rewards when they take risk associated with patient outcomes.
It is one of the two new payment paths that fall under the Quality Payment Program which will be determining Medicare Part B payment adjustments. Providers who wish to go the furthest toward delivering high-quality, efficient, and coordinated care may take up Advanced APM path. Successful participation in this enables you to earn incentive of 5% from 2019.
Advanced APMs:
  • Comprehensive primary care plus (CPC+)
  • Comprehensive ESRD care (CEC) - two-sided risk
  • Next generation ACO model
  • Shared savings program-track 2
  • Shared savings program-track-3
  • Comprehensive care for joint replacement (CJR) Payment model
  • Oncology care model (OCM) - two-sided risk
  • Vermont Medicare ACO initiative

How to earn Advanced APM incentive

It is only those eligible groups and clinicians who participate in qualifying Advanced APMs that are eligible for Advanced APM incentive payments. Those providers who participate in other Medicare payment models are not eligible. However, they are eligible, if their program qualifies to be advanced APM under the rules of CMS and if they meet a few of the participation needs.
Participation in advanced APM enables you to earn 5% incentive payment in 2019 (for participation in Advanced APM in 2017), under the following conditions:
  • If you have seen 20% of your Medicare patients via advanced APM
  • If you have received 25% of Medicare Part B payment via advanced APM
Meeting Advanced APM qualifying participation needs necessitates providers to send in the quality data as required by their Advanced APM. The specific model's website will direct providers about sending in quality data related to their Advanced APM.
Those who wish to leave Advanced APM in the year 2017 must ensure that they have seen the required number of patients or received the necessary payments via Advanced APM to be able to qualify for the 5% incentive. In case you have not met these thresholds, it is required that you submit data as part of the MIPS program. This helps avoid negative payment adjustment.