Navigating MIPS and Alternative Payment Models-Navigating MIPS and Alternative Payment Models [PowerPoint]

Navigating MIPS and Alternative Payment Models [PowerPoint]

Pdf Summary

The article, authored by Rachel Carey, Esq., provides a comprehensive update and strategic guidance for orthopedic providers navigating the 2025–2026 Medicare Quality Payment Program (QPP), with a focus on the transition toward Alternative Payment Models (APMs), including MIPS Value Pathways (MVPs) and the APM Performance Pathway (APP).<br /><br />Key points include:<br />- The QPP operates mainly as a downside risk program where Medicare withholds 9% from fee schedule payments, which clinicians must earn back by achieving a performance score typically around 75/100 to avoid penalties. Though positive payments are possible, rewards have been modest.<br />- CMS aims to move all traditional Medicare beneficiaries into accountable payment models by 2030, introducing ambulatory specialty models and mandating MVP subgroup reporting in 2026. Orthopedic providers should expect coexistence of traditional MIPS and MVPs, emphasizing strong performance across both approaches.<br />- Participation is determined annually at the clinician level by meeting specific thresholds in Part B volume, patients, and services. Reporting can be done individually, as groups, or as MVP subgroups; group reporting often leads to higher scores but requires widespread engagement.<br />- Orthopedic practices should not rely on facility-based scoring alone due to uncertainties around hospital value-based purchasing scores and should report directly to mitigate risk of penalties.<br />- Compliance risks include audit exposure from incomplete or inaccurate reporting, False Claims Act liabilities for knowingly false submissions, and the requirement for thorough documentation and truthful attestations.<br />- MVPs offer streamlined and specialty-aligned measures designed to reduce reporting burden and provide enhanced feedback, with mandatory subgroup reporting beginning in 2026.<br />- The APP simplifies reporting for APM participants but depends on the performance infrastructure of entities such as ACOs, which orthopedic clinicians often join via Medicare Shared Savings Program ACOs. However, ACO participation is no guarantee of positive adjustments.<br />- Orthopedic providers are encouraged to build Value-Based Entities (VBEs) to collaborate with hospitals and post-acute providers under the Anti-Kickback Statute and Stark Law safe harbors, to facilitate value-based care coordination and risk-sharing arrangements.<br />- The removal of the separate Advanced APM bonus shifts incentives toward long-term sustained operational improvements, with greater weight on the Physician Fee Schedule conversion factor.<br />- Orthopedic leaders must annually review eligibility, carefully select reporting pathways, maintain data integrity, and ensure audit readiness while negotiating clear ACO contracts detailing shared savings and compliance provisions.<br /><br />In summary, orthopedic providers face a complex payment landscape requiring proactive performance management, strategic participation in emerging models like MVPs and APMs, rigorous compliance, and collaborative value-based care structures to optimize financial outcomes under Medicare’s evolving policies.

Keywords

Medicare Quality Payment Program

Orthopedic providers

Alternative Payment Models

MIPS Value Pathways

APM Performance Pathway

Value-Based Entities

Medicare Shared Savings Program

Compliance risks

Audit readiness

Value-based care coordination