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Part 2 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment looks at alternatives to participation in the Merit-based Incentive Payment System (MIPS).

For physical therapists (PTs), required participation in MIPS seems like the big news in the US Centers for Medicare and Medicaid Services (CMS's) proposed 2019 physician fee schedule. And it is big news—but it's just a part of an even bigger picture known as the Quality Payment Program (QPP), the real heavyweight in the proposed rule.

It's actually QPP that PTs, occupational therapists, social workers, and clinical psychologists would be required to participate in beginning in 2019. MIPS is just 1 way of doing it (part 1 of this series covered some of the must-knows about how that system works). But CMS also proposes other ways that PTs might participate, mostly by way of Advanced Alternative Payment Models (AAPMs) or through an option that involves a Medicare Advantage demonstration.

So what should you consider when weighing the non-MIPS alternatives for participating in QPP? Here are a few basic concepts to keep in mind.

Don't get overwhelmed. AAPMs are complicated—but they're not impossible to understand.
First, about AAPMS: they are a subset of alternative payment models (APMs). To quality as an AAPM, according to the proposed fee schedule, the model must meet the following 3 criteria:

  • Require at least 75% of all eligible clinicians to use certified electronic health record technology (CEHRT) in 2019 for all CMS-created APMs, and by 2020 for so-called "other payer" APMs
  • Use quality measures that are comparable to those used in MIPS
  • Put some skin in the game by bearing financial risk for underachieving—CMS is proposing that the risk would need to be equal to 8% of the average estimated total Medicare Parts A and B revenues of providers and suppliers in the APM, or 3% of the expected expenditures that an APM entity is responsible for under the APM

Under the proposed rule, PTs who fully participate in an AAPM—that is, PTs who meet or exceed the relevant payment amount or patient count threshold for the year based on participation in an AAPM to become Qualifying APM Participants (QPs)—would not be required to comply with MIPS and would be eligible for payment adjustments (depending on the AAPM’s payment arrangement) as well as a 5% Medicare bonus

There are 2 kinds of AAPMs to choose from.
In the proposed rule, there are 2 varieties of AAPMs that would be open to PT participation: "Medicare Option" AAPMs and "All-Payer Combination Option" AAPMs.

The Medicare Option path proposed for 2019 includes CMS-created models such as the Comprehensive Care for Joint Replacement Model (but only the CEHRT track), the Next Generation ACO Model, the Medicare ACO Track 1+, and others. To get a better idea of this grouping, check out the current list of Medicare AAPMs on the CMS website.

For payment years 2021 and later, eligible clinicians may become QPs through a combination of participation in Medicare AAPMs and Other Payer AAPMs—a so-called "All-Payer Combination Option." This path allows providers to take a hybrid approach by participating in both a Medicare AAPM(s) and a CMS-approved AAPM(s) provided by Medicaid and other payers. Under this option, QPs are assessed by CMS through participation in both AAPMs.

The real question: would you qualify?
The AAPM-based QPP option allows participants to be exempted from MIPS and opens up the possibility of a 5% annual payment bonus (beginning in 2021 for the 2019 performance year) in addition to payment adjustments up or down; however, certain patient or payment thresholds must be met.

What are the thresholds? Again, it depends on which AAPM path you're pursuing. For payment year 2021 (performance year 2019), in order to be considered a QP in the Medicare Option path, you must have provided services through Medicare AAPM(s) for at least 35% of your Medicare Part B patients or have earned at least 50% of all Medicare Part B payments through the AAPM(s).

The All-Payer Combination is a little more complicated because it involves quotas for both Medicare and total payments and patients: at least 25% of Medicare Part B payments and at least 50% of all payments through AAPMs, and at least 20% of Medicare Part B patients and at least 35% of all patients served by way of the AAPMs.

It's also possible that if you don't meet these thresholds, you can participate via a "partial QP threshold" option, with lower payment and patient thresholds. Partial QP participants are not subject to the MIPS reporting requirements and payment adjustments unless they choose to report to MIPS, but they do not qualify for the 5% bonus.

CMS has proposed a possible QPP participation option based on Medicare Advantage.
It's called the Medicare Advantage Qualifying Payment Arrangement Demonstration (MAQI), and under the proposed fee schedule, it would work like this: providers who participate "to a sufficient degree" with a qualifying payment arrangement through a Medicare Advantage organization could be exempted from MIPS reporting and payment adjustments. Providers also wouldn't be required to meet the QP thresholds associated with the AAPM options, but they would need to apply for the demonstration project in advance. CMS has issued a fact sheet that goes into more detail on the plan.

Part 3 of the series: beyond QPP—the end of functional limitation reporting, future coding changes that could affect physical therapist assistant payment, and a telehealth shift.


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