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E2 – Qualifying Alternative Payment Model Participants


In our second QPP podcast, John Feore, one of our alternative payment experts, talks about the Advanced APM option and its qualifications.
“In performance years 3 and beyond (2019+), the minimum threshold increases, but revenue or patients associated with other payer Advanced APMs may be counted toward the increased threshold.” John Feore, Avalere


John Feore , Associate Principal, Center for Healthcare Transformation

John Feore advises healthcare providers, plans, and life sciences companies on the transformation of the healthcare system.

Listen to Others in This Series

E3 – Positioning for Success in the Merit-Based Incentive Payment System

E1 – Navigating MACRA in the First Performance Year


John: My name is John Feore, and I am a director in the Avalere Center for Payment & Delivery Innovation. This is the second of three Avalere podcasts discussing various elements of the Quality Payment Program (QPP). In this podcast, I will answer the following important question: “Are you a Qualifying APM Participant?”

As discussed in our first podcast, the QPP was brought about by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the sustainable growth rate formula, and through the QPP, creates two paths for clinicians participating in Medicare: (1) the Merit-based Incentive Payment System (MIPS); and (2) Advanced Alternative Payment Models (Advanced APMs).

Eligible clinicians that sufficiently participate in Advanced APMs during a performance year will be exempt from MIPS and will instead receive a 5% bonus payment regardless of how they perform under the Advanced APM. Following a familiar two-year lag methodology and as aligned with MIPS, performance in 2017 will dictate payment in 2019. The 5% bonus payment will be available for six consecutive years. Afterward, beginning in 2026, eligible clinicians that sufficiently participate in Advanced APMs will receive a 0.75% conversion factor update to the fee schedule, while all other clinicians under MIPS will receive a 0.25% update.

What is an Advanced APM?

Let’s quickly review what it means to be an Advanced APM.

An Advanced APM is an alternative payment model that: (1) requires participants to use certified health IT; (2) pays providers based on quality measures comparable to those required under MIPS; and (3) requires that the APM entity bear more than nominal financial risk. APMs that meet these criteria to be Advanced APMs in 2017 include the Medicare Shared Savings Program downside risk Accountable Care Organizations Tracks 2 and 3, the Next Generation ACO model, downside risk Oncology Care Model, Comprehensive Primary Care Plus demonstration, and risk-bearing Comprehensive ESRD Care Models.

Qualifying APM Participant

What does it mean to be a Qualifying APM Participant?

For the first two performance years of the Quality Payment Program (2017 and 2018), a Qualifying APM Participant (QP) must receive at least 25% of their total Medicare Part B payments or see at least 20% of their total Medicare patients through the APM entity to receive the 5% bonus payment. Partial QPs are those clinicians whose percentages equal 20% of Medicare payments or 10% of Medicare patients. Partial QPs are not eligible for the 5% Advanced APM bonus but have the option of participating in MIPS.

In performance years 3 and beyond (2019+), this minimum threshold increases, but revenue or patients associated with Other Payer Advanced APMs may be counted toward the increased threshold. These Other Payer Advanced APMs must meet requirements that are similar to Medicare Advanced APM requirements. Other Payer Advanced APMs may include Medicaid, commercial insurance, and potentially Medicare Advantage.

Three Snapshots

To determine whether a clinician meets the payment or patient count threshold to be considered a QP, CMS will conduct three snapshots during each performance year. Each snapshot may add previously unidentified eligible clinicians to the APM entity. Once eligible clinicians are identified though a snapshot, they will be considered a QP regardless of whether they are identified in later snapshots. The three snapshots will occur on March 31, June 30, and August 31. Each snapshot will have a two-month claims runout, with an estimated two additional months for CMS to make the final QP determination.

QP determination will be made at the group or APM Entity level, with an affirmative decision that will apply to all individual eligible clinicians who are part of a given APM Entity. For eligible clinicians that participate in multiple Advanced APMs but none of them meet the QP threshold, CMS will determine QP eligibility on an individual basis. In this scenario, CMS will look at the individual clinician’s combined revenue and patients from all Advanced APMs to determine whether he or she would meet the minimum thresholds.

CMS estimates that the majority of Advanced APMs will qualify as QPs and, more specifically, that between 70,000 and 120,000 clinicians will be considered QPs for performance year 2017. As CMS increases the number of Advanced APM options available to clinicians, this number could double in 2018 and represent as much as 25% of clinicians required to participate in the QPP. Our third podcast on the QPP will focus on the Merit-based Incentive Payment System.

Thank you.

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