Assistance with Alternative Payment Models

The recent SGR repeal had several key aspects. The most immediately impactful was a failure to postpone the implementation of ICD 10 CM which will now go into effect October 1st, 2015. It also implemented an annual increase in the PFS of 0.5% from 2015-2019. The payment rates will then be frozen from 2020-2025. Beginning in 2026 the payments rates will either increase by 0.25% annually for those participating in merit based incentive programs or 0.75% annually for those participating in alternative payment models.

The merit based incentive program is known as MIPS. The Physician Quality Reporting System (PQRS), EHR Incentive Program, Physician Value-Based Modifier (VBM) will become a single payment adjustment for the physician beginning in 2019. Beginning in 2019, physician payments could be adjusted anywhere from -4% to +12%. This will increase to an adjustment of -9% or +27% by 2022.

Providers participating in the Alternative Payment Models will be allowed to opt out of the MIPS program. From 2019-2024, providers qualifying for the APM program will be provided a 5% bonus payment annually based on the total Medicare allowed amounts for that particular year. APM participants must qualify by meeting increasing thresholds for the percentage of revenue received through APM’s. Qualifying APM’s are defined by law as those that require the provider to take on “more than nominal” financial risk.