Alternative Payment Models

Certain clinicians have the option to participate more extensively in Medicare’s Value-Based Care system. In the Advanced APM track of the Quality Payment Program, such providers may earn a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. Those that achieve these thresholds are excluded from MIPS.

WHAT are APMs?

According to the CMS,

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.


MIPS-eligible clinicians, who 1) would like better participation incentives, and 2) fall under one of the categories the CMS has deemed eligible for that year, can choose to contribute to APMs, rather than MIPS.


There are two main types of APMs for clinicians to participate in, MIPS APMs and Advanced APMs. MIPS APMs are available to MIPS-eligible clinicians who apply to participate. The data submission requirements closely resemble that of MIPS, but with more focus on the goal of the APM. Advanced APMs, on the other hand, have their own set of eligibility requirements and data submission standards.

Participating in Advanced APMs

As of 2019, Advanced APM participants earn a 5 percent incentive payment if they a) receive 50% percent of their Medicare Part B payments through an Advanced APM, or b) see 35 percent of their Medicare patients through an Advanced APM. Additionally, 75 percent of practices, within the Advanced APM entity, must be using certified EHR Technology.

For more information about Advanced APMs, including the full list of participation models, click the button below:

Participating in MIPS APMs

The eligibility requirements for MIPS APMs are the same as those for MIPS. Thus, for 2020, clinicians and groups that apply (and are accepted) for a MIPS APM are eligible if they 1) bill $90,000 or more in Medicare Part B allowed charges, 2) see more than 200 Part B-enrolled Medicare beneficiaries, AND 3) provide 200 or more covered professional services to Part B patients.

The data submission requirements are similar to the standard MIPS program, with different weights given to the four performance categories. The distribution is:

  1. Quality – 50%
  2. Improvement Activities – 20%
  3. Promoting Interoperability – 30%
  4. Cost – 0%

The goal is for the data submitted to better reflect the purpose of the respective APM. In other words, the CMS reduces the reporting requirements of categories already accounted for by APMs, so clinicians can more closely focus on the task at hand.

For more information about MIPS APMs, including the full list of participation models, click the button below:

Contact us today to receive more information or speak with a Valletta billing expert.



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