Some eligible clinicians may be participating in an Alternative Payment Model (APM) that does not qualify as an Advanced APM, according to the Centers for Medicare & Medicaid Services (CMS) standards. CMS created a separate category of APMs called Merit-based Incentive Payment System (MIPS) APMs. These models include MIPS-eligible clinicians and, like Advanced APMs, hold eligible participants accountable for the cost and quality of care provided. Participants in MIPS APMs receive special MIPS scoring under the APM scoring standard.

The Centers for Medicare & Medicaid Services (CMS) have posted several models that are MIPS APMs in 2020. Eligible clinicians and their groups should also check their participation status to see if CMS has determined your APM status. 

MIPS APM Criteria

For an APM to be considered a MIPS APM, it must:

  1. participate in the APM under an agreement with CMS or by law or regulation; 
  2. require that APM Entities include at least one MIPS eligible clinician on a Participation List; 
  3. bases payment incentives on performance (either at the APM entity or eligible clinician level), on cost/utilization, and quality measures.

For eligible clinicians participating in MIPS APMs, the Low Volume Threshold is calculated at the APM entity level, also referred to as the Accountable Care Organization (ACO) level.

MIPS APM Scoring

The APM Scoring Standard accounts for activities already required by the APM to reduce duplication of reporting and allow clinicians to focus on the goals of the APM. Therefore, the MIPS performance category weighting and reporting requirements are different than the general MIPS scoring standard.

The performance category weights used to calculate the MIPS final score under the APM Scoring Standard for the 2020 performance period are as follows:

  1. Quality: 50 percent
  2. Improvement Activities: 20 percent
  3. Promoting Interoperability: 30 percent
  4. Cost: 0 percent

Why participate in a MIPS APM?

While qualifying participants in a MIPS APM will not be eligible for the 5 percent bonus payment, they will have MIPS special reporting requirements and receive special MIPS scoring under the “APM scoring standard.” This will help relieve the burden of full participation in the MIPS program.

Also, note that most Advanced APMs are also MIPS APMs. In these cases, a clinician who fails to meet the eligibility requirements to qualify in an Advanced APM may instead be scored under MIPS, according to the APM scoring standard.