Medical Billing News

Yesterday the Centers for Medicare and Medicaid Services (CMS) released its anticipated proposed rule which details how the Agency intends to implement the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM) Medicare reimbursement methodologies which will replace the Medicare Sustainable Growth Rate Formula (SGR).

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which is the legislation responsible for creating these new systems, outlines the broad framework for how they will function but left it to CMS rulemaking to develop the granular details for how these new Medicare reimbursement methodologies will function. Specifically, this 1,000-page document proposes the criteria, definitions and other key details that are necessary for implementing MIPS and APMs. CMS will solicit and consider stakeholder comments before issuing a final rule before the end of the year. So stay tuned for further analysis and updates.

In regards to APMs, the proposed rule:

1. Defines APMs that are approved by CMS for purposes of the APM incentive payments outlined in MACRA implementation as “Advanced APMs” and “Other Advanced APMs” and the qualification criteria. Will notify public on list of qualified APMs by January 1, 2017. Table 32 in the proposed rule lists many existing APMs and outlines whether or not they would qualify as an Advance APM as proposed.
   1. Advanced APM, an APM must meet three requirements:
      1. Require participants to use certified EHR technology;
      2. Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS; and
      3. Be either a Medical Home Model or bear more than a nominal amount of risk for monetary loses.
2. Other Payer Advanced APM, a commercial or Medicaid APM must meet three requirements similar to the CMS Advanced APM requirements:
   1. Require participants to use certified EHR technology;
   2. Provide payment based on quality measures comparable to those used in the quality performance category of MIPS; and
   3. Be either a Medicaid Medical Home Model that is comparable to Medical Home Models as elaborated in the proposed rule or bear more than a nominal amount of risk for monetary loses.
3. Would identify individual eligible clinicians by a unique APM participant identifier using the individuals’ TIN/NPI combinations, and to assess as an APM Entity group all individual eligible clinicians listed as participating in an Advanced APM Entity to determine QP status for a year.
4. Proposes the method that CMS would use to calculate and disburse the APM Incentive Payments.
5. Definition of Physician-Focused Payment Models (PFPMs), and outlines criteria for evaluation and implementation.
6. Proposes a definition of “nominal amount of financial risk” which APMs must include in order to be certified as an Advanced APM.

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