Understanding Advanced APM Bonuses

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Allison Brennan, MPPSVP, Government AffairsNAACOS

Advanced APMs

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• Performance year 2020 relates to the 2022 payment year for the 5% Advanced APM bonus

• CMS list of Advanced APMs includes these and more:o MSSP Tracks 1+, 2 / Pathways Basic Level E, Enhanced Tracko Next Generation ACO modelo Comprehensive ESRD Care Model (Large Dialysis Organization (LDO)

arrangement and non-LDO two-sided risk arrangement)o Comprehensive Primary Care Plus (CPC+)o Oncology Care Model (two-sided risk arrangement)o Comprehensive Care for Joint Replacement Payment Model (CEHRT

Track)o Vermont All-Payer ACO Model Initiative o Maryland Total Cost of Care Modelo BPCI Advanced

New APMs on the Horizon

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More information on the models can be found on the Innovation Center webpageNAACOS will advocate to allow ACO participation in other models and to minimize disruption to ACOs as a result of model overlap

Model Voluntary / Mandatory

Advanced APM

Primary Care First Voluntary Yes

Direct Contracting Voluntary Yes

Kidney Care First Voluntary Yes

Comprehensive Kidney Care Contracting

Voluntary Yes

ESRD Treatment Choices Mandatory No

Radiation Oncology Mandatory Yes

PY 2020 QP Thresholds

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BACKGROUNDQualifying APM Participants (QPs):Advanced APMs must have a certain proportion of patients or payments go “through” the APM. The ACO is evaluated collectively and if it meets/exceeds the thresholds, those ECs are designated as QPs and earn 5% bonuses

QP Threshold Type: Payment Patient CountMedicare

QP 50% 35%Partial QP 40% 25%

All-Payer CombinationQP 50% (25% Medicare) 35% (20% Medicare)Partial QP 40% (20% Medicare 25% (10% Medicare)

Advanced APMs

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• CMS calculates this threshold in the following manner

Attributed beneficiariesAttribution-eligible beneficiaries

• Attributed beneficiaries: those attributed to the Advanced APM Entity according to the Advanced APM’s attribution rules, based on the latest available list of attributed beneficiaries

• Attribution-eligible beneficiaries: (similar to ACO assignable beneficiaries) min. of one claim for E&M service by an EC/group within an APM Entity during the QP performance period

• CMS QP determination is calculated at the Advanced APM Entity level collectively across all ECs

Advanced APM Bonus

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• The 5% Advanced APM Bonus is earned by achieving QP status

• Advanced APM bonuses are not counted as expenditures for ACOs when determining shared savings/losses (unlike MIPS adjustments)

• The Performance Year is two years prior to the Payment Adjustment Year.

• The “Base Year” for the Advanced APM bonus is the year in between.o Ex: 2018 Performance Year

2019 Base Year 2020 Payment Adjustment Year (bonus paid in the latter half of

the year)

Calculating the Advanced APM Bonus

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• The 5% amount is based on Estimated Aggregate Payment Amounts for Part B Covered Professional Services furnished by the QP during base year (ex. 2019)

• CMS uses claims data for claims with dates of service during the base year (ex. 1/1/2019 through 12/31/2019) as long asthey were processed by 3/31 of the payment adjustment year

• CMS combines the estimated aggregate amounts for Part B covered professional services across all billing TINs associated with a QP’s NPI. (Note: this includes TINs outside of the ACO)

• Bonus is based on the aggregate paid (not allowed) amounts.

Calculating the Advanced APM Bonus

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• Specific items included in the base amount:o Supplemental service payments (not separately paid

under the PFS, often PBPM payments for care management or separately billable services). These payments are included IF they are made in lieu of services paid under the PFS. (ex. CPC+ care management)

o Cash flow mechanisms: Ex. NG PBP (monthly payment in exchange for a reduction in PFS revenue). These are accounted for by including the money that would have been paid for Part B Covered Professional Services.

Calculating the Advanced APM Bonus

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• Specific items included in the base amount:o Payments for the TC of imaging and other diagnostic

services if they are paid under the PFS and furnished by an EC

o Professional services furnished at a Method II CAH are considered “covered professional services”, and therefore those payments attributed to the EC, as identified using the attending NPI, are included.

o Professional charges for Part B drug administration

Calculating the Advanced APM Bonus

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Specific items not included in Advanced APM bonus calculation

• Shared savings payments to ACOs

• Payment for Part B drugs

• Technical component of imaging and other diagnostic services paid outside of the PFS

• Bonuses for: MIPS, VM, PQRS, MU, HPSA Physician Bonus, HPSA Surgical Incentive Payment, PCIP

• Net reconciliation amounts from CMS to participants in BPCI Advanced and other similar programs

• Payments for services by ECs in RHCs and FQHCs

Calculating the Advanced APM Bonus

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• Processed claims from the base year already have a 2% sequestration cut so there is no additional sequestration cut to the Advanced APM bonus.

• CMS pays the bonus to the TIN associated with the QP's participation in the Advanced APM entity that met the QP thresholdo If, when the bonus is paid, an EC is no longer affiliated with that TIN,

CMS pays the bonus to the TIN listed on the EC’s 588 (EFT form)

• If an EC becomes a QP through participation in multiple Advanced APMs, CMS divides the APM Incentive Payment amount between the TINs associated with the QP's participation in each Advanced APM during the QP Performance Period.

o Payments are divided in proportion to the amount of payments associated with each TIN that the EC received for covered professional services during the QP Performance Period.

CMS MACRA Resources

• CMS QPP Resource Library

• Resources from CMS on 2019 Advanced APM bonus, including list of specific codes used in base amount.o 2019 APM Incentive Payment (links to zip file)

• 2020 CMS Advanced APM details, available here.

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NAACOS MACRA Resources

NAACOS’ resource The ACO Guide to MACRA is an in-depth guide that reviews everything that ACOs need to know about MACRA implementation

NAACOS resource details Advanced APM QP calculations compared to ACO data and calculations

Other NAACOS MACRA resources, updates and comment letters available on our MACRA page

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Advocacy

• NAACOS is working to develop legislation, the “Value Act” to address some key MSSP and Advanced APM issueso Advanced APM issues: extend bonus, address program

overlap, prevent QP thresholds from risingo MSSP: increase BASIC shared savings, more time before

risk, increase cap on risk adjustment, fix benchmarking flaw*, keep Enhanced voluntary, eliminate high-/low-revenue distinction, bring back ACO Investment Model

* the benchmarking issue is often referred to as the “rural glitch” and would remove ACO assigned beneficiaries from regional benchmark component. Help led your support!!! Go to our Take Action page today to contact your lawmakers and urge passage.

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Q&A

Thank you!

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