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5 Reasons Organizations in Advanced Alternative Payment Models Are Not Ignoring MIPS

March 15, 2017


Since the January 1st start of the Quality Payment Program (QPP), provider organizations are deciding where focusing their efforts can yield the greatest benefits and minimize the most risks under MIPS and/or alternative payment models (APMs). In particular, organizations participating in advanced APMs (AAPMs) are addressing the myriad of aspects of a given model necessary to perform well and avoid financial penalties. Hence, one might assume that such organizations are ignoring MIPS, due to AAPM entities typically being excluded from MIPS, and placing their full attention only on AAPM operations.

However, in reality, many AAPM organizations are finding that understanding and addressing MIPS is still a priority.


Here are the top 5 reasons why:

1, Clinicians joining the AAPM after August 31st are very likely subject to full MIPS for the year.
For each AAPM entity, CMS maintains an APM participation list determining which clinicians are deemed to be participating in a given AAPM for the current year. The final participation list “snapshot” is August 31st, which means that a clinician joining an AAPM organization after August 31st is not deemed to be participating in that AAPM for the current year. In addition, as AAPM organizations are currently few in number, it is very likely that the clinician’s previous organization is not an AAPM organization. Consequently, the clinician would be subject to full MIPS for the current year if the clinician exceeds the MIPS low-volume threshold and is not a new Medicare clinician. AAPM organizations on-boarding new clinicians in the last 1/3 of the year realize the need to manage and monitor MIPS for them.

2. Some clinicians may not be eligible for the organization’s chosen AAPMs.
An multi-specialty organization may choose to participate in an AAPM, such as CPC+, for which only certain specialties are eligible, e.g. primary care clinicians for CPC+. Therefore, the organization would have to manage the program requirements of the AAPM as well as for MIPS as applied to non-AAPM eligible clinicians.


3. An organization may choose to exclude certain clinicians from an AAPM.
Some AAPMs, such as the Next Generation ACO program, allow organizations to specify exactly which clinicians should be participating. For example, an organization might intentionally choose to exclude some of its primary care clinicians from a Next Generation ACO for operational or performance reasons. Those clinicians would then be subject to MIPS if not otherwise excluded.


4. An organization wants to know how clinicians would otherwise have fared under MIPS had they not been in the AAPM.
One of the more interesting things we’ve heard in the field is the desire by some AAPM organizations to understand what their clinicians’ MIPS scores and payment adjustments would have been had those clinicians not participated in the AAPM. A reason cited is that organizations are increasingly evaluating on an annual basis whether participation in a given AAPM is the best option for their organization. Should they decide to switch to a different AAPM, then there could be one or more transition years during which many of their clinicians are subject to full MIPS.


5. Leverage MIPS for current or future operational reasons.
This one is more of a prediction, but for which we are seeing signs in the market. In about 18 months, when 2017 MIPS scores for an estimated 600,000+ clinicians are published by CMS, MIPS will become the industry’s most pervasive and visible physician rating system. The fact that every MIPS score is indelibly and identifiably tied to a clinician, even if that clinician switches organizations, will have broad impacts on areas such as physician credentialing, contracting, compensation and network formation. Commercial payers are beginning to examine the mechanics and utility of the MIPS score to potentially leverage it in how they evaluate and manage relationships with clinicians. We’ve heard organizations looking to use MIPS as an internal measure of relative clinician performance, such as within physician compensation plans. A prediction is that estimating and comparing MIPS scores across clinicians, even for those clinicians who are not subject to the formal MIPS program, will become an important tool in how an organization internally manages its clinicians.

We are increasingly seeing that understanding and tracking MIPS is becoming “good hygiene” even for AAPM organizations who on the surface may seem to be able to ignore MIPS.  But going below the surface and into what’s happening in the field reveals a different story.

This article was originally published on SA Ignite and is republished here.

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