Can Physicians Be Exempt From MIPS With a Non-CMS APM?
The short answer is often yes. Participating in a non-CMS Advanced Alternative Payment Model (APM) can, under specific circumstances, qualify physicians for exemption from the Merit-based Incentive Payment System (MIPS), offering significant potential benefits for eligible clinicians.
Understanding APMs and MIPS: The Regulatory Landscape
The Centers for Medicare & Medicaid Services (CMS) designed the Quality Payment Program (QPP) to reward value and outcomes in healthcare. QPP consists of two tracks: MIPS and Advanced APMs. MIPS consolidates several existing Medicare quality reporting programs into a single program that measures performance across four categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. APMs, on the other hand, are payment approaches that incentivize high-quality and cost-efficient care. Understanding how these interact is crucial in answering Can Physicians Be Exempt From MIPS With a Non-CMS APM?
What is a Non-CMS APM?
A non-CMS APM is an alternative payment model that isn’t directly administered by CMS. These APMs can be developed and run by commercial payers, state Medicaid agencies, or other entities. They often share similar goals as CMS APMs, such as improving care coordination, reducing costs, and enhancing patient outcomes. Crucially, the QPP rules outline specific criteria that non-CMS APMs must meet for participating clinicians to be considered Qualified APM Participants (QPs) or Partial QPs.
Benefits of MIPS Exemption Through Non-CMS APMs
Achieving MIPS exemption through participation in a qualified non-CMS APM offers several advantages:
- Avoiding MIPS Penalties: MIPS penalties can significantly reduce Medicare payments. Exemption protects physicians from these financial losses.
- Focus on Value-Based Care: Participating in an APM encourages a shift towards value-based care, rewarding better outcomes rather than just volume.
- Potential for APM-Specific Incentives: Non-CMS APMs often offer their own financial incentives for achieving quality and efficiency targets, adding to the financial benefits.
- Reduced Administrative Burden: In some cases, reporting requirements under a non-CMS APM may be less burdensome than MIPS reporting, freeing up time for patient care.
Key Requirements for MIPS Exemption via Non-CMS APMs
For physicians to be exempt from MIPS due to participation in a non-CMS APM, the APM must meet specific criteria related to:
- Use of Certified EHR Technology (CEHRT): The APM must require participants to use CEHRT to document and share clinical information.
- Quality Measures: The APM must base payments on performance on quality measures comparable to those used in MIPS.
- Financial Risk: The APM must bear more than nominal financial risk. This means the APM bears financial risk of monetary losses based on performance. The specific thresholds vary, but the APM must demonstrate a significant downside risk for poor performance.
- QP/Partial QP Status: Clinicians must demonstrate they meet QP or Partial QP status through their participation. CMS determines this based on data submitted through the APM.
How to Determine Eligibility for MIPS Exemption
The process to determine if Can Physicians Be Exempt From MIPS With a Non-CMS APM? involves several steps:
- Identify Participating APMs: Determine which non-CMS APMs your practice participates in.
- Review APM Requirements: Scrutinize the specific requirements of each APM to ensure it meets CMS’s criteria for a qualified APM.
- Assess QP/Partial QP Status: Analyze your participation data to estimate whether you meet the QP or Partial QP thresholds. CMS has detailed information available regarding the percentages of Medicare payments or patients required to qualify.
- Verify with CMS: While you can estimate eligibility, the final determination rests with CMS. CMS will review data submitted by APM entities and clinicians to determine QP/Partial QP status.
- Prepare for Potential Audits: Maintain thorough documentation of your APM participation and performance data in case of audits.
Common Mistakes and Pitfalls
- Assuming Automatic Exemption: Do not assume that simply participating in a non-CMS APM automatically grants MIPS exemption. Careful verification of the APM’s qualifications and your QP/Partial QP status is essential.
- Incorrect Data Submission: Accurate and timely data submission is vital. Errors or omissions can jeopardize your chances of achieving QP status.
- Lack of Documentation: Failing to maintain adequate documentation to support your participation and performance within the APM can be problematic during audits.
Table: Comparing MIPS and Advanced APMs
| Feature | Merit-based Incentive Payment System (MIPS) | Advanced Alternative Payment Models (APMs) |
|---|---|---|
| Payment Adjustment | +/- based on performance across 4 categories | Potential for bonus payments; MIPS exemption |
| Financial Risk | No significant financial risk | Must bear more than nominal financial risk |
| Reporting Burden | Can be significant | Potentially lower if APM reporting is streamlined |
| Focus | Performance across various metrics | Value-based care and outcomes |
Importance of Understanding the QP/Partial QP Thresholds
Meeting QP or Partial QP thresholds is paramount. The thresholds are based on the percentage of Medicare payments you receive through the APM or the number of Medicare patients attributed to you through the APM. CMS sets these thresholds annually, so staying informed is crucial. Failure to meet the thresholds means you will be subject to MIPS reporting.
Conclusion: Navigating the Complex Landscape
Determining whether Can Physicians Be Exempt From MIPS With a Non-CMS APM? requires a thorough understanding of QPP rules, APM requirements, and individual clinician participation data. By carefully assessing their eligibility and maintaining proper documentation, physicians can leverage non-CMS APMs to achieve MIPS exemption and embrace value-based care.
Frequently Asked Questions (FAQs)
If I participate in multiple non-CMS APMs, does my participation add up toward QP status?
Yes, under certain circumstances. CMS will aggregate participation across multiple APMs when determining QP status. However, each APM must still meet the requirements for a qualified APM. CMS considers the attributed patient count and Medicare payment data across all qualifying APMs to determine if the QP thresholds are met.
What happens if I think I’m a QP, but CMS determines I’m not?
If CMS determines that you don’t meet QP status, you will be subject to MIPS reporting requirements. It’s crucial to have a contingency plan in place, including preparations for MIPS data submission, in case your QP status is not confirmed.
Does participation in a CMS APM automatically exempt me from MIPS?
Participation in an Advanced CMS APM generally does lead to MIPS exemption. However, specific requirements must still be met. Ensure you fully understand the terms of your CMS APM participation to guarantee you qualify as a QP.
Can a small practice benefit from participating in a non-CMS APM and seeking MIPS exemption?
Yes, small practices can benefit greatly. MIPS reporting can be particularly burdensome for smaller practices. Achieving MIPS exemption can free up valuable resources and allow them to focus on patient care and APM-related initiatives.
What role does CEHRT play in MIPS exemption through non-CMS APMs?
CEHRT is crucial. The use of CEHRT is a core requirement for non-CMS APMs to qualify for MIPS exemption. CEHRT facilitates data sharing, care coordination, and performance measurement, all of which are essential for value-based care.
How often are the QP/Partial QP thresholds updated?
CMS updates the QP/Partial QP thresholds annually. It is essential to stay informed about these changes to accurately assess your eligibility for MIPS exemption. Check the QPP Resource Center for the most up-to-date information.
Are there specific types of non-CMS APMs that are more likely to qualify for MIPS exemption?
Generally, APMs with robust risk-sharing arrangements and a strong emphasis on quality improvement are more likely to meet the requirements for MIPS exemption. Look for APMs that align with CMS’s value-based care goals.
What documentation should I maintain to support my claim for MIPS exemption?
Maintain comprehensive documentation, including: APM participation agreements, performance reports, data submission records, CEHRT usage records, and any communication with the APM entity. This documentation is critical in the event of an audit.
What is the difference between a QP and a Partial QP?
A QP receives a bonus payment and is exempt from MIPS. A Partial QP receives a smaller bonus payment (generally less than a full QP) and may be subject to simplified MIPS reporting. The specific thresholds for payments and MIPS reporting will depend on the specific year.
If my non-CMS APM ends mid-year, what happens to my MIPS status?
If your non-CMS APM ends mid-year, your MIPS status will depend on the timing and extent of your participation. Consult with CMS or a QPP advisor to determine your MIPS reporting requirements for that performance year.
Where can I find more information about non-CMS APMs and their qualification requirements?
The QPP Resource Center on the CMS website is the best source of information. Additionally, you should contact the non-CMS APM entity directly to understand its specific requirements and performance reporting processes.
Can participation in a State Medicaid APM qualify physicians for MIPS exemption?
Yes, participation in a State Medicaid APM can potentially qualify physicians for MIPS exemption, provided the APM meets all the criteria set forth by CMS for a qualified APM. Review the APM’s terms and conditions carefully to ensure compliance with CMS requirements.