MACRA

Year Two - 2018

Fee - for Pay - for - Pay - for -

- Service Reporting Performance

The Journey to Healthcare Payment Reform

MACRA Timeline
• Congress passed the Medicare Access and CHIP Reauthorization Act of
April, 2015 2015

• Department of Health and Human Services issued a Notice of Proposed

April, 2016 Rulemaking for MACRA

• CMS released the Final Rule which was published in the Federal Register
October,
2016
on 11/4/2016

January,
• First Quality Payment Program performance year begins
2017

• Second Quality Payment Program performance year begins

January,
2018
MACRA Highlights
• Repealed Medicare’s Sustainable Growth Rate (SGR) physician fee
schedule formula

• Replaced / Consolidated existing PQRS, Meaningful Use and Value-

Based Modifier reporting programs

• Established the new value based reimbursement system called the

Quality Payment Program (QPP)
Eligible for Quality Payment Program (QPP)
Reporting in 2018
Individuals and Groups Consisting of the Following Eligible Providers:
• Physician (MD, DO, DMD, DDS) beyond 1st year of Medicare Part B participation
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist

Meeting the Following Thresholds During 1 of 2 Determination Periods:

Sept. 1, 2016 – Aug. 31, 2017 OR Sept. 1, 2017 – Aug. 31, 2018 (Includes a 30-day claims runout)

• Bill Medicare more than $90,000 of allowed charges a year (Medicare Advantage claims do not apply to the required
threshold)
• Provide care for more than 200 Medicare patients a year (Medicare Advantage patients do not apply to the required
threshold)
• It is estimated that 35% of Medicare clinicians will fall below the volume participation threshold in 2018,
creating a more competitive program
Two Quality Payment Program (QPP)
Pathways
Merit-Based
Incentive
System (MIPS)
Advanced
Alternative
Payment Models
(AAPMs)
Quality Payment Program (QPP) Path #1
• One of the Two Quality
Payment Programs (QPP)
• Replaces the PQRS, EHR
Meaningful Use and Value
MIPS
Merit-Based
Based Modifier Programs Incentive Program
• Consists of Four Categories:
• Quality
• Clinical Performance Improvement
Activities
• Advancing Care Information
• Cost
Eligible for MIPS Reporting for 2018
• Eligible Individual Providers (EPs)

• Group of Eligible Providers – TIN with multiple NPI numbers

• Virtual Groups – Groups of practices (TINs) each with 10 or less clinicians and solo
practitioners exceeding low-volume threshold that are scored for MIPS as if a group
sharing a single TIN
• No location nor specialty restrictions on the formation of virtual groups
• Practices must sign agreement and apply to CMS by December 31st
• CMS predicts approximately 16 virtual groups will form in 2018
• CMS published a virtual group toolkit

• MIPS APMs – Defined as certain APMs that include eligible MIPS providers as
participants

• Partial Qualifying Advanced APMs

• *Reporting optional
MIPS, PQRS, MU & VBM Payment Adjustment
Timeline
• MIPS payment adjustments (+4%/-4% in 2019) are based on Medicare Part B annual payments for covered services
and items
• Medicare Part B drug payments are included in the calculation of MIPS incentive and penalty payments

• Annual inflationary increases of .5% to the CMS fee schedule applies to the payment years of 2016 – 2019
• An annual inflationary increase of .25% to the CMS fee schedule applies to the payment year of 2026, onward

Last Last payment (X = Budget Neutrality Factor )

performance year for PQRS, MIPS +4%*X MIPS +5%*X MIPS +7%*X MIPS +9%*X
year for PQRS, MU & VM 3/31 Deadline 3/31 Deadline
MU & VM for submitting for submitting
2017 MIPS data 2018 MIPS data

2016 2017 2018 2019 2020 2021 2022+

First Second First MIPS Second

performance performance payment year MIPS
year for MIPS year for MIPS payment
MIPS -4% year MIPS -5% MIPS -7% MIPS -9%
Performance Year MIPS Reporting Weights
2019
2018

Cost 10% Clinical Practice

Clincal Practice
Improvement
Improvement
Activities 15%
Activities 15% Cost 30%

Advancing Care
Information
25%

Quality 30%
Advancing Care Info
25%

Quality 50%
2018 Performance Year MIPS Reporting
Weights for Hospital-Based & Non-Patient
Facing Providers • Hospital-Based Providers are defined as those
performing 75% of services in POS 19, 21, 22,
or 23 for twelve months beginning with 9/1 of
Clincal
Practice
the calendar year preceding the performance
Improvement
Activities 15%
year
• Beginning in 2019, Hospital-Based Providers
will have the option to be scored according to
their facility’s performance.
• Non-Patient Facing are defined as individual
eligible providers who perform fewer than 100
Quality 85%
procedures with patient facing codes annually
and/or groups where at least 75% of eligible
clinicians within the group or virtual group are
designated as non-patient facing
2018 Performance Year MIPS Reporting Basics

Clinical Practice Advancing Care

Quality Improvement Information Cost
Activities

12-Months 90-Days 90-Days 12-Months

50 Points 15 Points 25 Points 10 Points

100 Points
• Any MIPS EP or small group in a small practice (15 or fewer EPs) may earn up to 5
points to be added to their final composite score, as long as data is submitted on at
least 1 performance category in an applicable performance period

• Do Not Participate or Report and Receive a negative 5% payment penalty in 2020

2017 & 2018 MIPS Hardship Waivers for
Extreme and Uncontrollable Circumstances
• CMS is extending hardship waivers to EPs which have been affected by natural disasters
across the country which occurred during the 2017 MIPS performance period, including
Hurricanes Harvey, Irma, Maria and the California wildfires
• An interim final rule with comment period (CMS-5522-IFC) was published in the CY 2018 QPP final rule
with comment period
• CMS will use enrollment data listed in PECOS to identify EPs located in FEMA-designated
disaster areas including FL, GA, LA, PR, SC and some parts of TX and CA
• EPs will automatically be exempt from a 2017 performance period / 2019 payment year MIPS penalty, no
exemption application required

• EPs that do submit data /report for 2017 performance period will be scored on the data submitted
• This final rule with comment period applies to the 2018 MIPS performance period as well
• EPs will need to submit a hardship exception application by 12/31/2018

• This policy does not apply to APMs

 MIPS Performance Thresholds (PT) and
Payment Adjustments
• In 2018 the break even performance threshold (PT) is 15, for Providers to receive a 0% neutral
payment adjustment
• To achieve a PT = 15 one of the following reporting scenarios must be met:
• Report all required Improvement Activities (for maximum of 40 points)
• Meet the Advancing Care Information base score and submit 1 Quality measure that meets data completeness
• Meet the Advancing Care Information base score, by reporting the 5 base measures, and submit one medium-
weighted Improvement Activity
• Submit 6 Quality measures that meet data completeness

• Providers meeting a performance threshold (PT) above 15 may earn base incentives up to 5%
• PT = 15.01-69.99 eligible for positive adjustment greater than 0%
• PT = 70+ eligible for positive adjustment greater than 0% AND exceptional performance/additional
performance bonus at 0.5%+

• Providers not meeting a performance threshold (PT) of 15 will receive a negative payment adjustment
• PT = 3.76-14.99 will receive a negative payment adjustment greater than -5% and les than 0%
• PT = 0-3.75 will receive a negative payment adjustment of -5%
 MIPS Budget Neutrality Factor
• Due to the budget-neutral design of MIPS, the total amount of performance threshold bonuses
awarded to EPs will continue to be equal to the total amount of penalties assessed
• CMS’ adjustment to the 2018 low-volume participation threshold is expected to reduce the number of
participating EPs by 35%; making the program more competitive
• CMS has set aside an additional $500 million each year between 2017-2022, to fund high performing bonuses
awarded to EPs with a composite performance score of 70 points or higher

• The budget neutrality factor, X, is determined by total composite scores of all MIPS-eligible
providers falling below, meeting or exceeding performance thresholds (PT)
• Ex: If total number of providers achieving a high composite score is low, the neutrality factor, X, can be
increased up to a factor of 3
• Ex: If total number of providers achieving a high composite performance score is higher, the neutrality factor, X,
can be lowered down to 1 to ensure budget neutrality

• The budget neutrality factor, X, is capped at 3.0

• Reaching the 3.0 cap would only be feasible if more providers received penalties rather than incentives as a
result of their overall composite performance scores, since the budget neutrality must be maintained
• Ex: For performance year 2018, maximum base incentive payment adjustment could = 5% x budget neutrality
factor of 3.0 = 15%
• Ex: For performance year 2018, maximum possible incentive for exceptional performance could = 5% x
budget neutrality factor of 3.0 + 10% bonus = 25%
Meet the Required MIPS Composite
Performance Scores (CPS) for 2018 using
• DocsInk’s Mobile Charge Capture platform allows individual providers to submit their
Quality measures via the claims-based method, required for the Quality category in the
performance year of 2018

• DocsInk’s Care Coordination platform allows providers to meet two medium-weighted Clinical
Practice Improvement Activity (CPIA) measures, providing ½ the points needed (20 points) in
the CPIA category to qualify for the maximum 40 points in the performance year of 2018

• DocsInk Secure Communication platform meets all HIPAA standards and simply interfaces
with certified EHR (CEHRT) used by EPs to meet the required Advancing Care Information (ACI)
measures in the performance year of 2018

• DocsInk’s Chronic Care Management (CCM) and Transition Care Management (TCM) solutions
promote better health outcomes and reduction of readmissions, designed to reduce the per
capita cost of attributed beneficiaries and Medicare spending per beneficiary (MSPB) used to
score the Cost performance category in the performance year of 2018
 MIPS QUALITY Reporting for 2018
• Replaces PQRS and quality portion of Value-Based Modifier programs
• For 2018, report at least 6 measures or 1 specialty-specific measure set on 60% of
applicable patient encounters (meeting the data completeness threshold) for a period of
12 months, one of which much be an Outcome measure or High-priority measure, to
receive a score of 15 points which is sufficient to avoid a negative payment adjustment in
2019
• Over 270 individual quality measures and 30 specialty measure sets published
• Find them here at CMS’ interactive website: https://qpp.cms.gov/measures/quality

• 3-point floor for all measures

• 60% data completeness threshold for all submission methods except for Web Interface and
CAHPS
• Measure that do not need data completeness criteria will earn 1 point instead of 3
• Small practices with less than 15 EPs will continue to get 3 points when data completeness is not met
• 20-case minimum for all measures except for all-cause hospital readmission measure, which
has a 200–case minimum requirement for groups of 16 or more
MIPS QUALITY Reporting for 2018
• Quality Measures are worth from 1-10 points each, with the exception of topped out
measures
• Topped out measures with benchmarks that have been topped out for at least 2
consecutive years will be worth up to 7 points
• Measures are defined as topped out when meaningful distinctions and improvement in
performance can no longer be made
• 6 Quality Measures have been finalized as topped out in 2018 which will be scored on a maximum of 7
points, including:
• Perioperative Care – Quality Measure ID: 21
• Melanoma – Quality Measure ID: 224
• Perioperative Care – Quality Measure ID: 23
• Image Confirmation of Successful Excision of Image-Localized Breast Lesion – Quality Measure ID: 262
• Optimizing Patient Exposure to Ionizing Radiation – Quality Measure ID: 359
• Chronic Obstructive Pulmonary Disease – Quality Measure ID: 52
MIPS QUALITY Reporting for 2018
• Total Quality performance score is the sum of the points assigned, divided by the total
points available, and then weighted to count for 50% of total MIPS score
• Quality performance scoring will be based on the rate of improvement at the
performance category level
• Bonus for additional high priority measures (up to 10% of possible total)
• Bonus for end-to-end electronic reporting (up to 10% of denominator for performance
category)
• Bonus for the treatment of complex patients based on a combination of Hierarchical
Condition Categories (HCCs) and number of dually eligible patients treated (up to 5
points)
• DocsInk’s Mobile Charge Capture platform allows individual providers to submit their
Quality measures via the claims-based method, required for the Quality category in the
performance year of 2018
 MIPS QUALITY Reporting Methods for 2018
Claims Qualified Registry or CMS Web Interface
(individual providers only) EHR Vendors QCDR
QCDR (groups of 25 or more)

• Individual providers reporting via Claims must report on at least 50% of all MIPS eligible
provider’s Medicare Part B patients
• If reporting via Registry, EHR, or Qualified Clinical Data Registries (QCDR) data must be
submitted on at least 50% of all MIPS eligible provider or group’s patients; regardless of
payer
• If reporting via Qualified Clinical Data Registries (QCDR) data must be reported on all
approved measures
• If reporting via CMS Web Interface data must report on all included measures & must
populate data for first 248 consecutively ranked and assigned beneficiaries; or 100% of
patients if less than 248
MIPS CLINICAL PRACTICE IMPROVEMENT
ACTIVITY (CPIA) Reporting for 2018
• The Clinical Practice Improvement Activity (CPIA) category does not replacing any existing legacy
reporting programs, and is meant to emphasize improving patient outcomes

• CPIA score is determined by dividing the sum of points earned by the provider by 40 maximum
points, and then weighted to count for 15% of total MIPS score

• 40 maximum points available based on 112 activities in 9 categories found here at CMS’
interactive website: https://qpp.cms.gov/measures/ia
• Heavy weighted activities = 20 points
• Medium weighted activities = 10 points

Patient Safety
Expanded Population Care Beneficiary
& Practice
Patient Access Management Coordination Assignment
Assessment

Integrating Emergency
Participation Achieving
Behavioral & Preparedness
in APM Health Equity
Mental Health & Response
MIPS CLINICAL PRACTICE IMPROVEMENT
ACTIVITY (CPIA) Reporting for 2018
• Groups that are small (less than 15 providers), rural, or located in a health
professional shortage area (HPSA), or non-patient facing providers must only
complete 1 high-weighted or 2 medium-weighted activities for 90 days to receive
full credit of 40 points

• If reporting as a group or a virtual group, only 1 eligible provider needs to report

on CPIA for the entire group or virtual group to get full credit

• Eligible providers participating in a certified Comprehensive Primary Care Plus

(CPC+), Patient-Centered Medical Home (PCMH), Shared Savings Program Track 1,
2, 3, or Oncology Care Model will receive full credit of 40 points
• 50% of practice sites within a TIN or TINs that are part of a virtual group must be
recognized as a PCMH to receive full credit for CPIA in 2018

• Eligible providers participating in other APM’s will earn half credit of 20 points
and can report additional activities to increase their score
MIPS CLINICAL PRACTICE IMPROVEMENT
ACTIVITY (CPIA) Reporting Methods for 2018

Qualified Registry QCDR EHR CMS Web Group Attestation

(groups of 25 or more)

• For 2018, all eligible providers, groups and third party entities submitting CPIA data
must use a “YES/NO” response, certifying that all activities have been performed

• Administrative claims method is meant to be utilized only when feasible

• Ex: Eligible providers or groups using telehealth modifier “GT”, could get automatic credit
for this activity
DocsInk’s Care Coordination platform allows providers to meet two Clinical Practice
Improvement Activity (CPIA) measures, providing ½ the points needed (20 points) in
the CPIA category to qualify for the maximum 40 points for the performance year of
2018
MIPS CLINICAL PRACTICE IMPROVEMENT
ACTIVITY (CPIA) Measures for 2018
Two CPIA Measures Achieved with DocsInk’s Care Coordination Platform

ACTIVITY SUBCATEGORY ACTIVITY

ACTIVITY NAME ACTIVITY DESCRIPTION
ID NAME WEIGHTING

Care transition Implementation of practices/processes for care IA_CC_10 Care Medium

documentation practice transition that include documentation of how a MIPS Coordination
improvements eligible clinician or group carried out a patient-
centered action plan for first 30 days following a
discharge (e.g., staff involved, phone calls conducted in
support of transition, accompaniments, navigation
actions, home visits, patient information access, etc.).

Implementation of Establish standard operations to manage transitions of care IA_CC_11 Care Medium
additional activity as a that could include one or more of the following: Establish Coordination
result of TA for improving formalized lines of communication with local settings in which
empaneled patients receive care to ensure documented flow
care coordination
of information and seamless transitions in care; and/or
Partner with community or hospital-based transitional care
services.
MIPS ADVANCING CARE INFO (ACI)
Reporting for 2018
• Replaces Meaningful Use program
• Comprises 25% of total MIPS score for all eligible providers

• CMS will reweight the ACI performance category to 0 and reallocate the 25% to the
Quality performance category for EPs meeting special status criteria
• Automatic reweighting for:
• hospital-based providers
• non-physician practitioners
• non–patient facing EPs & groups
• ambulatory surgical center-based EPs
• Reweighting through an approved application (due by 12/31 of the performance period) for:
• EPs in small practices (15 or fewer clinicians) facing hardship
• EPs whose EHR was decertified
• EPs facing providers facing significant hardship
 MIPS ADVANCING CARE INFO (ACI)
Reporting for 2018
Qualified Registry EHR CMS Web Interface Attestation QCDR
(groups of 25 or more)

• Find ACI objectives and measures here at CMS’ interactive website:

• https://qpp.cms.gov/measures/aci

• Based on the Burden Reduction Aim EPs may use either the 2014 or 2015 Certified
Electronic Health Technology (CEHRT)

• Two separate measure sets are available based on EHR technology utilized
• 2018 transitional measures (modified state 2 meaningful use)
• 2018 measures (stage 3 measures)

DocsInk Secure Communication platform meets all HIPAA standards and simply
interfaces with certified EHR (CEHRT) used by EPs to meet the required Advancing Care
Information (ACI) measures in the performance year of 2018
 MIPS ADVANCING CARE INFO (ACI)
Reporting for 2018
• Base Score = Possible 50 points
• Report a 1 in the numerator and denominator or “yes” for selected measures as required
• CMS finalized exclusions for certain measures:
• E-prescribing exclusion
• Health Information Exchange Measures exclusions
• Send summary of Care Measure exclusion applies to EPs who transfers or refers a patient <100
times during performance year
• Request/Accept Summary of Care Measure exclusion applies to EPs who have encountered
patient <100 times during performance year
• Select “YES” to the exclusion and submit a null value for the measure
• Successfully meeting and reporting all of the Base Score Measures is required and failure to
do so will result in a zero in the ACI category for MIPS reporting
MIPS ADVANCING CARE INFO (ACI)
Reporting for 2018
• Performance Score = Possible 90 points
• Each measure reported will be calculated individually by dividing the numerator by the
denominator
• Some performance measures are also included in the base measure category, but will earn
additional points towards performance score for values higher than 1 in numerator
• EPs and groups will earn 10% for reporting to any one of the Public Health and Clinical Data
Registry Reporting measures as part of the performance score
• Bonus Score = Possible 25 points
• 5 bonus points for reporting to a public health or clinical registry that was not included
under the ACI performance score
• 10 bonus points for using a certified EHR (CEHRT) for at least 1 of 21 identified Improvement
Activities under CPIA category
• 10 bonus points for reporting ACI Objectives and Measures for exclusively using only 2015
edition CEHRT
• CMS intends this to be a one-time only bonus offered in performance period 2018
MIPS COST Reporting for 2018
• Replaces 2 cost measures formerly used in Value-Based Modifier program
• Total per capita cost of care for attributed beneficiaries
• Medicare spending per beneficiary (MSPB)

• Comprises 10% of total 2018 MIPS performance year score for eligible providers
• Will comprise 30% of total MIPS score in performance years 2019 and beyond

• Administrative claims will be used to calculate EP and group performance, and no other
reporting is necessary

• The 10 episode-based cost measure adopted for the 2017 MIPS performance period will
not be used for the 2018 performance period
• CMS is developing new episode-based measures with input from stakeholders and plans
to solicit feedback on some of these measures during the fall of 2018

• New proposed measures are expected to be introduced in future rulemaking before

they are included in MIPS
 MIPS COST Reporting for 2018
• The Cost Performance category is scored using both achievement points earned and by
calculating improvement
• Total MIPS Cost score = total # of Cost achievement points earned by EP / total # of available achievement
points + the cost improvement score
• EP performance compared to performance of other MIPS EPs and groups during the same/current
performance period
• Can’t see performance benchmarks ahead of time
• Cost achievement points earned are calculated using the average of the per capita cost and
MSPB measures
• If only 1 measure can be scored, that score will equal the performance achievement score

• Cost improvement scores are calculated by comparing performance in current MIPS

performance period to performance in immediately preceding performance period
• Improvement scoring based on statistically significant changes at the measure level
• Improvement score only calculated when there is sufficient data showing EP used same identifier in 2
consecutive performance periods and was scored on the same cost measures for 2 consecutive periods
• Up to 1% is available for Cost improvement
MIPS COST Reporting for 2018

DocsInk’s Chronic Care Management (CCM) and Transition Care Management

(TCM) solutions promote better health outcomes and reduction of readmissions,
designed to reduce the per capita cost of attributed beneficiaries and Medicare
spending per beneficiary (MSPB) used to score the Cost performance category in
the performance year 2018
Quality Payment Program (QPP) Path #2

• One of the Two Quality

Payment Programs (QPP)

• Subset of APMs which

AAPMs
Advanced Alternative
Provides Incentives for High Payment Models
Quality and Cost-Effective
Care, Requiring Shared Risk
Related to Performance
Standards
Qualifying Advanced APM (AAPM)
Entities for 2018

Comprehensive Care Comprehensive Medicare Shared

for Joint Replacement Primary Care Plus Savings Program ACOs
(CEHRT track) (CPC+) Model Tracks 1+,2 & 3

Comprehensive ESRD
Oncology Care Model
Care Model Next Generation ACO
(Two-Sided Risk
(Two-Sided Risk Model
Arrangement)*
Arrangement)*

CMS estimates 185,000 – 250,000 clinicians will participate in AAPMs in 2018

* Indicates not currently accepting new applicants
Advanced APM (AAPM) Specifics
for 2018
• Exempt from MIPS reporting

• Report Quality Measures as normally required by CMS using GPRO Web Interface at
the group TIN level

• The Qualifying Participant (QP) performance period for each payment year will be
from January 1 – August 31, of the calendar year that is 2 years prior to the
payment year

• Receive annual lump sum payment bonus = 5% of previous year’s Part B annual
payments for covered professional services; regardless of level of performance
• Receive a 0.5% higher fee schedule update from 2026 forward
 Eligibility for Advanced APM (AAPM)
Participation in 2018
Qualifying Advanced APM Requirements:
• Requires APM group participants use certified EHR technology (CEHRT)
• Provides services for payment based on quality measures comparable to those in MIPS
• Either bears more than a nominal financial risk for monetary losses (representing at least 8%
of average estimated total Medicare A & B revenues or 3% of the AAPM Entity’s expected
expenditures), or is a Medical Home expanded under CMS Innovation Center Authority with
total potential risk of 2.5% of average estimated total Medicare A & B revenues
• Medical Home model revenue-based standard applies to entities with <50 EPs in their parent organization
• Entities enrolled in Round 1 of the CPC+ model is exempt from this EP volume requirement

Meeting the Following Thresholds:

• Receive 25% of total Medicare payments through an Advanced APM (AAPM)
• Treat 20% of Medicare patients through an Advanced APM (AAPM)
• Starting in 2019 performance period, “All-Payer Advanced APMs” can contribute to thresholds
Eligibility for Advanced APM (AAPM)
Participation in 2018
• Qualifying participant (QP) determination occurs at the Advanced APM (AAPM) Entity

• There can be multiple AAPM individual provider and/or group/TINs (QPs) within an
Advanced APM (AAPM) Entity
• The collective threshold score from all individual and group/TIN determines whether the
AAPM Entity is a Qualified Participant (QP), Partially Qualified Participant (PQP) or MIPS
APM Eligible Participant
• All providers in the AAPM receive the same QP determination

• CMS determines the eligible provider group QP status by calculating the threshold
score 3 times during the performance year; March 31, June 30 and August 31 of the
performance period
• Eligible providers will be notified of the QP status after each QP determination period
• A provider’s QP status cannot change for the performance year once they are deemed a
QP by one of the snapshots
Payment Incentives for Advanced APM
(AAPM) Participation in 2018
• The 5% incentive is paid at the TIN qualifying participant (QP) level of the AAPM Entity
based on the Part B annual payments for covered professional services received during
the incentive payment base period (year that falls between the performance year and
payment year); regardless of level of performance

• If eligible provider bills Medicare Part B in multiple AAPM group TINs (in the same or
multiple AAPM entities), the totals will be combined to calculate the 5% incentive
• The 5% incentive is paid to the group TIN under the AAPM entity, where the eligible
provider is determined to be a qualifying participant (QP) at the time of the incentive
payment year
• If a provider is determined to be a QP in multiple AAPM entities, the incentive will be split
among the TINs proportionally

• If a provider is not deemed a QP through any one single AAPM entity but through their
aggregated totals in multiple AAPM entities, then CMS splits the incentive between the TINs
proportionally
Partial Qualifying Advanced APM (AAPM)
(Partial QP) for 2018

• CMS determines the Partial Qualifying AAPM (Partial QP) classification at the group
level of AAPMs; not the individual clinician level
• Defined as any group of AAPM eligible providers, that do not collectively meet the
necessary Medicare 25% payment or 20% patient threshold scores, but meet 20% or
10% respectively
• Not eligible to receive the 5% APM lump sum incentive payment
• May opt out of the MIPS reporting program without any negative payment
adjustment, but the decision is made at the entity level and applies to all eligible
providers
• Receives favorable MIPS scoring
• The Partial QP group may decide as an entity to report under MIPS on behalf of all its
identified participating eligible clinicians, subjecting the group to both positive and
negative payment adjustments
MIPS APMs for 2018
• MIPS APM entities meet the following criteria:
• Participate under an agreement with CMS (not another payer)
• Have at least one eligible provider on an APM participation list
• Base payment incentives determined by performance, cost and quality measures

• It is possible for an APM to be a MIPS APM, an Advanced APM (AAPM), both or

neither
• Not eligible to receive the 5% APM lump sum incentive payment
• MIPS APM eligible providers belong to an APM (advanced or non-advanced) who are
also subject to MIPS reporting
• Eligible providers must be on an APM participation list on one of the four snapshot
dates of March 31, June 30, or August 31 during the performance period
• Fourth snapshot to determine participation in Full TIN MIPS APMs (MSSP) on December 31
MIPS APM Reporting for 2018
• MIPS APM classification provides streamlined reporting and special scoring for participating
eligible providers and all MIPS APM payment adjustments are applied at the TIN/NPI Level
• All scores from eligible providers participating in a MIPS APM entity are aggregated so that
each provider receives the same final MIPS score
• MIPS APM QPs automatically receive full credit for Improvement Activities category
MSSP ACOs & Next Generation ACOs Scored as MIPS APMs
CATEGORY REPORTING METHOD SUBMISSION METHOD %
Quality CMS Web Portal Group Submission for Entire ACO’s TIN # 50%

Improvement Activities Any Approved Submission *Group Submission for Each TIN # Participating in 20%
Method ACO for Averaged Score

Advancing Care Any Approved Submission *Group Submission for Each TIN # Participating in 30%
Method ACO for Averaged Score
 All-Payer Advanced APMs for Performance
Year 2019
• Beginning in performance year 2019, providers may become a QP in an All-Payer Advanced APM
based on a combination of 2 pathways:
• Participation in Advanced APMs within Medicare fee-for-service
• Participation in Other Payer Advanced APMs

• For the 2019 performance year, the All-Payer AAPM QP determinations will be allowed at the APM-
level using 3 snapshot dates of March 31, June 30 & August 31
• Determinations are conducted so that the Medicare fee-for-service Option is applied prior to the All-Payer
Combination Option
• EPs who do not meet the thresholds to become QPs under the Medicare Option may then request a QP
determination under the All-Payer Option

• All-Payer AAPM QP payment and patient volume threshold requirements will be at 25% and 20%
respectively
• All-Payer AAPM Partial QP payment and patient volume threshold requirements will be at 20% and
10% respectively
• Qualifying Other Payer Advance APM criteria includes the following:
• Minimum of 50% of EPs use CEHRT
• Provides services for payment based on quality measures comparable to those in MIPS
• Participants bear more than a nominal amount of financial risk or is a Medical Home expanded under CMS
Innovation Center Authority
All-Payer Advanced APMs for Performance
Year 2019
• There will be 2 processes allowing a payment arrangement to be determined as an Other
Payer Advanced APM
• Voluntary Payer-Initiated determinations:
• Medicaid requests accepted from 1/2018 – 4/2018 with a determination posted by 9/2018
• CMS-Multi Payer requests accepted from 1/2018 – 6/2018 with a determination made by 9/2018
• Medicare plans (including Medicare Advantage plans) requests accepted from 1/2018 – 6/2018 with a
determination made in 9/2018
• Other payers (including commercial and private payers) not available for performance year 2019,
requests accepted 1/2018 – 12/2018 and determination made by 12/2019
• Eligible Clinician-initiated determinations:
• Medicaid requests accepted from 9/2018 – 11/2018 with a determination posted by 12/2018
• CMS-Multi Payer requests accepted from 8/2019 – 12/2019 with a determination made by 12/2019
• Medicare plans (including Medicare Advantage plans) requests accepted from 8/2019 – 12/2019 with
a determination made in 12/2019
• Other payers (including commercial and private payers) not available for performance year 2019,
requests accepted 8/2019 - 12/2019 and determination made by 12/2019
All-Payer Advanced APMs for Performance
Year 2019
• Beginning in performance year 2019, the 4 payer types that may have payment
arrangement that qualify as Other Payer Advanced APMs include the following:
• Title XIX (Medicaid)
• Medicare Health Plans (including Medicare Advantage)
• CMS Multi-Payer Models
• Other commercial & private payers