Navigating MIPS and Alternative Payment Models-Navigating MIPS and Alternative Payment Models [Job Aid]

Navigating MIPS and Alternative Payment Models [Job Aid]

Pdf Summary

This document serves as a comprehensive guide to managing Medicare reporting and participation in value-based care programs, particularly focusing on MIPS (Merit-based Incentive Payment System) and Alternative Payment Models (APMs). Key points include:

1. <strong>Submission and Compliance:</strong> All submissions must be documented. At least 50% of clinicians should perform Improvement Activities for 90 days to comply with CMS regulations. Avoid false submissions as they risk False Claims Act violations. CMS can audit providers without alleging intent-based fraud.

2. <strong>Participation Requirements:</strong> Providers must participate in MIPS if all thresholds are met: Medicare Part B revenue over $90,000, more than 200 Part B patients, and over 200 Part B services. If only some thresholds are met, they may opt in voluntarily.

3. <strong>Optimizing Scores:</strong> To avoid payment penalties, a score of 75/100 or higher is recommended. Reporting should include six quality measures (with at least one outcome measure) and at least one Improvement Activity. Use certified EHRs, registries, or approved vendors, and prioritize measures tied to high benchmarks, fewer readmissions, lower post-acute costs, and accurate documentation.

4. <strong>Avoiding Facility-Based Reporting Pitfalls:</strong> Providers should not rely solely on facility-based MIPS scoring, as CMS does not calculate facility-based scores without report submissions. Facility-based scoring is a backup option, not a primary strategy.

5. <strong>Exploring MVPs and APMs:</strong> MIPS Value Pathways (MVPs) offer a more specialty-relevant, connected reporting approach with fewer measures, though registration is required. APMs provide infrastructure support, analytics, and opportunities for shared savings. Establishing Value-Based Entities (VBEs) and partnerships with hospitals and post-acute care providers is encouraged to align incentives and comply with AKS/Stark safe harbors.

6. <strong>Reporting Options:</strong> Providers can choose between Traditional MIPS (flexible but administratively heavy), MVPs (simpler, specialty-focused), or App Participation Programs (via APMs, offering simplified reporting but linked to ACO performance).

The document emphasizes starting early in value-based care participation, aligning incentives, and utilizing partnerships to meet CMS’s goal of universal APM participation by 2030.

Keywords

Medicare reporting

MIPS

Alternative Payment Models

CMS compliance

Improvement Activities

Value-Based Care

Quality Measures

Facility-Based Reporting

MIPS Value Pathways

Accountable Care Organizations