What is an APM?
An 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.
What is an Advanced APM?
Advanced APMs are a subset of APMs and let practices earn more for taking on additional risk related to their patients' outcomes. By going further in improving patient care and taking on more risk, Advanced APMs may earn a 5% incentive payment across the board from 2019 to 2025 and also may be eligible to receive higher payments under the Physician Fee Schedule starting in 2026. They may also be excluded from the MIPS reporting requirements and payment adjustment.
To be an Advanced APM, an APM must meet the following three criteria:
- Require participants to use certified electronic health record technology;
- Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of the Merit-based Incentive Payment System; and
- Either: (1) be a Medical Home Model expanded under CMS Innovation Center authority; or (2) requires participating APM Entities to bear a significant financial risk.
Comprehensive List of APMs and Advanced APMs: Visit the CMS Innovation Center website and search for a specific Advanced APM.
Do RDNs working in an Advanced APM in 2021 qualify for program bonuses?
Beginning in 2017, CMS included RDNs in the list of professionals who may become a Qualified APM Participant and become eligible to receive an annual 5% APM lump sum bonus. QPs also are excluded from MIPS. These bonus payments are available in years 2019 to 2025 based on Part B billed services in 2017 to 2023, respectively. In addition, RDNs who are QPs will be eligible to receive higher payments under the Physician Fee Schedule starting in 2026.
What are the requirements to become a Qualifying APM Participant?
RDNs in Advanced APMs may qualify as a QP if in their group's APM they meet the following thresholds:
RDN receives at least 50% of their Medicare Part B payments through an Advanced APM or RDN sees at least 35% of their Medicare patients through an Advanced APM.
RDNs may also qualify as a QP through the "All-Payer and Other Payer Option."
The All-payer and Other Payer Option allows for clinicians to combine their participation in a Medicare APM with their participation in another CMS approved other-payer Advanced APM (Medicare Advantage, Medicaid and private payers) in order to meet QP qualification thresholds. For more information about the All-payer combination option visit the QPP website.
What if RDNs DO NOT meet the requirements to become a Qualifying APM Participant?
RDNs in Advanced APMs who do not qualify as a QP, may be eligible to become a Partial Qualifying APM Participant (Partial QP) and can choose to report voluntarily under MIPS. Based on the MIPS participation option chosen, the RDN may or may not be subject to any payment adjustments.
What are the requirements to become a partial Qualifying APM Participant?
RDN receives at least 40% of their Medicare Part B payments through an Advanced APM or RDN sees at least 25% of their Medicare patients through an Advanced APM entity during the QP performance period (January 1 – August 31).
What do RDNs who DO meet the CMS requirements to become Qualifying APM Participants need to know?
- RDNs should make sure their individual NPI is included on the list of QPs for each Advanced APM they participate with in order to receive these financial incentives.
- As a QP, RDNs will need to send in the quality data required by their Advanced APM. RDNs can work with each Advanced APM to identify measures being submitted and what data they need to document or report. In addition, their model's website will tell RDNs how to send in their Advanced APM's quality data.
- If RDNs leave the Advanced APM during 2021 they should make sure their APM has seen enough patients or received enough payments through an Advanced APM to qualify for the 5% bonus. As a reminder, if they haven't met these thresholds, RDNs may have other participation options under MIPS.
For more information on Advanced APMS visit the QPP website.