Another Option…

Last week, we dove into MIPS methodology as the main component of MACRA. Staying on top of all this requires planning because if you intend to participate in MIPS, your payments in 2019 will depend on your performance in 2017. However, there is an alternative strategy that we should consider. If we choose the APM (Alternative Payment Model) track, and our model qualifies by CMS standards, we can forget about being paid (or not being paid) through MIPS.

So what is a qualified APM? Is it any less risky?

Examples of qualified APM’s include: (like MIPS, we are still waiting for the holes in the Swiss cheese of policy to get filled)

  • A Medicare Shared Savings Program ACO;
  • A PCMH model;
  • A bundled payment model

Additional models will be added as policy continues to be written. Now, to qualify for this track instead of MIPS, a minimum % of the physician’s revenue must be subject to some level of upside or downside risk. *NOTE: 25% at risk does not mean potential loss of 25% of revenue – it means that 25% of revenues would be subjected to a 5% (for example) upside or downside -it means 1.25% of revenues are at risk.


The first 5 years of the program, 2019-2023, require a commitment to APM’s as follows (we make the decision annually to continue or drop back to MIPS):


2019 – 2020 2021 – 2022 2023+
25% of Medicare revenues 50% of Medicare revenues


25% of Medicare revenues, 50% of ALL payer revenues

75% of Medicare revenues


25% of Medicare revenues, 75% of ALL payer revenues

* Until 2024: Annual lump sum bonus on fee schedule: 5%! – always read the small print!


For example, if a CIN (Clinically Integrated Network) is participating in an ACO (NRACO) and some practices are accredited PCMH’s, and 25% of Medicare revenues come through these programs, then the CIN practices qualify as an APM. This could be our scenario if we form a CIN. Furthermore, APM’s that don’t meet the threshold are considered “partially qualifying” BUT avoid MIPS penalties; they just don’t get the 5% bonus!

The bottom line: Forming a CIN and tackling this as a collective team has benefits beyond just Medicare reimbursements. Choosing APM affords us more financial certainty than MIPS.

Obviously there is more to come as the MACRA policy continues to be written. Every other week, we have been discussing a wide array of payment reform topics. If there is any topic that you would like more detail on, please email We are open to your requests.