MSSP Alternative Payment Models for ACO Providers

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Do you need more information about Qualifying Providers, Advanced APMs or bonus payments? Contact the Scripps ACO operations team.

Understanding Alternative Payment Models

The premise behind value-based reimbursement is simple: Providers are rewarded for delivering high-quality, cost-efficient care. But the methodologies behind calculating and distributing incentive payments are more complicated.

Scripps ACO’s reimbursement is tied to our status as an Advanced Alternative Payment Model (AAPM). But what does that mean? If you’re unsure how MACRA, MIPS and APMs are related — and how they impact you — you’re not alone.

Below you’ll find more information about key payment models and incentives, and how your participation in the Scripps ACO may make you a “Qualifying Provider” (QP).

What is MACRA?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) combined various Medicare incentive programs into a single program. As part of CMS’s efforts to phase out fee-for-service reimbursement in favor of value-based reimbursement, MACRA repealed and replaced the Sustainable Growth Rate (SGR) payment system.

Under MACRA there are two potential paths that link quality of care to incentive payments, known collectively as the Quality Payment Program. The first path is called the Merit-Based Incentive Payment System (MIPS), and the second is known as Advanced Alternative Payment Models (AAPMs).

What are the difference between MACRA’s MIPS and AAPM paths?

The Merit-Based Incentive Payment System (MIPS) brings together parts of three former Medicare programs: The Physician Quality Reporting Program (PQRS), the Value-Based Payment Modifier (VM) Program, and the Medicare Electronic Health Record Incentive Program (Meaningful Use).

MIPS requires reporting in four performance categories:

Quality
Promoting Interoperability (former known as Advancing Care Information, or ACI)
Improvement Activities
Cost

Under MIPS, eligible providers’ performance in each of these four weighted categories is combined to create the MIPS Final Score. This composite score determines future Medicare Part B payment adjustments ranging from -4 percent to +4 percent.

In comparison, Advanced Alternative Payments Models (AAPMs) let providers earn more rewards in exchange for taking on more risk related to patient outcomes. Providers who meet AAPM performance criteria earn a 5 percent lump sum bonus on Medicare Part B professional billings.

They also are exempt from MIPS reporting, and avoid the +/-4 percent MIPS adjustment.

Remember that Scripps ACO reports all quality and CAHPS measures on your behalf, except for Promoting Interoperability measures. Individual practices are responsible for reporting their own Promoting Interoperability data independent of Scripps ACO. Learn more about Promoting Interoperability reporting.

Have Scripps ACO physicians achieved Qualifying Provider status?

Yes. First, Scripps ACO achieved Advanced APM status for performance year 2017. Then, because Qualifying Providers (QPs) are determined at the entity level, all ACO participating providers were assessed together.

This means all Scripps ACO providers are exempt from MIPS and its reporting requirements until further notice. QP status is earned for one year at a time.

Moving forward, you can check your QP status using CMS’s interactive tool.

Learn more about CMS’s methodology for determining QP status.

How are advanced APM bonus payments distributed?

QP Bonus Payment Distribution Year	CY 2024	CY 2025	CY 2026
Bonus Percent	5%	3.5%	1.88%
Year of ACO Participation	2022	2023	2024
Year of Medicare Part B covered payments*	2023	2024	2025