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Advanced Alternative Payment Model

CMS had announced the criteria for participation in Merit-based Incentive Payment System (MIPS) back in July. From January 1, 2017, CMS will start the process of replacing the Medicare Sustainable Growth Rate Formula (SGR) methodology that is used to find the annual updates to Medicare Physician Fee Schedule (MPFS), with a “value-based” payment model that is connected to performance and quality.

At the time when it was initially announced, CMS stated that the Eligible Clinicians (ECs) has to report either MIPS data for the complete year and get the data compared to the other clinicians, or take part in the Advanced Alternative Payment Model that is approved by them. For the ECs who are participating in MIPS, the data reported in the year 2017 will lead to positive or negative MPFS payment adjustments in the year 2019.

Under the proposal that was announced in July, all MIPS Eligible Clinicians would be asked to report different measures that are aimed to assess and compare the data across different specialties. ECs will be getting a MIPS composite score that is solely based on the performance across the reporting categories like Resource Use, Practice Improvement, Quality, and Information Sharing. In the year 2019, MIPS participating ECs will have their Medicare payments adjusted negatively or positively.

Andy Slavitt, the Acting Administrator of CMS, announced in September that they are planning to back off its two-pronged approach to the Merit-based Incentive Payment System. Instead of that, CMS would be offering “flexibility” to report “some data” in 2017 and avoid payment penalties in the year 2019. He also added that ECs could submit partial year data to get a proportional positive or negative adjustment in 2019.

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Medicare Sustainable Growth Rate Formula

Submitting “some data” will help an EC to avoid negative payment adjustments in 2019 under MIPS. As per the announcement, this option is “designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019.” The announcement, however, does not offer any detail on the definition of “some data” and it is expected to be elaborated in the final rule.

The final rule is finished by CMS and is reviewed by the Office of Management and Budget (OMB) at present. We would need to wait until the rule is released to the public to know more about it. It is rumored that the final rule will be released by the end of October 2016.