2021 Quality Payment Program Final Rule: What the Biggest Changes Mean if You Report Using APM 

Beth Hickerson, Healthcare Transformation Consultant Practice Services

As the year draws to a close, the Centers for Medicare & Medicaid Services (CMS) have given us reason to start looking ahead to 2021: recently, the CMS released the Quality Payment Program (QPP) 2021 Final Rule.   

As many healthcare organizations and practices know, the QPP and the two tracks it creates, the Merit-based Incentive Payment System (MIPS) and the advanced Alternative Payment Models (APMs) have an outsized influence on how organizations are evaluated and reimbursed based on quality of care. Understanding the nuances and newly updated portions of each year’s QPP Final Rule are crucial to maximizing organization performance and reimbursement. So, what’s changed in the 2021 QPP Final Rule?  

In the 2021 QPP Final Rule, updates for APM entities and their participants are significant. Here’s what Medical Advantage’s expert MIPS consultants see as some of the biggest changes.

Introduction of APP, Sunsetting of APM Scoring Standard 

The most noteworthy change for clinicians reporting using the advanced APM is that the new APM Performance Pathway (APP) is being introduced. The APP is a new reporting framework for MIPS APM participants, like the MVP framework for individual clinicians and groups. It reduces the total number of quality measures that must be reported by a MIPS APM. The APP is optional for MIPS APMs in 2021, except for Medicare Shared Savings APMs. 

Alongside the introduction of the APP, CMS is sunsetting the APM scoring standard as of 2021, and will sunset the CMS web interface submission type as of 2022. The elimination of the CMS web interface has a huge impact on reporting for MIPS APMs, and APM entities should begin discussing alternate reporting options as soon as possible because there are many important variables to consider. One other notable change is that APM participants will now be evaluated for the low-volume threshold at the individual and group levels rather than the APM entity level.  

Expanded Reporting Options for APMs 

MIPS APM entities now have greatly expanded quality reporting options for MIPS. Previously, MIPS APMs were only able to report quality at the APM entity level using the CMS web interface. Starting in 2021, APMs will be able to select from multiple reporting options. 

First, they can choose to report under traditional MIPS  APM requirements or under the new APP framework. Second, APM entities can elect to submit quality measures using the CMS web interface, eCQMs, or MIPS CQMS via registry or QCDR.   These new options offer a great deal of flexibility that can be beneficial for APM entities, but they also introduce complexity and challenges that must be addressed.

MIPS APM participating clinicians and groups also have expanded options for MIPS reporting and scoring outside of their APM entity. In previous years, all APM participants automatically received the APM entity MIPS score and payment adjustment, regardless of any traditional MIPS reporting done by their practice group. Starting in 2021, individual clinicians that electively report at the TIN or TIN/NPI level will receive a final MIPS score that reflects their highest performance in the MIPS program, not necessarily the APM entity score. MIPS APM participants that report individually or as a group can choose to report under traditional MIPS or under the new APP framework.    

Considerations for MSSP ACOs 

Under the 2021 QPP Final Rule, there are some special considerations for Medicare Shared Savings (MSSP) ACOs. First and foremost: MSSP ACOs are required to choose the APP pathway for reporting purposes in 2021. This forced change will require MSSP ACOs to quickly make some key decisions to be prepared for full year reporting. In addition, CMS has finalized the new quality performance standard for MSSP ACOs which will scale the amount of shared savings and losses that the ACO receives based on its MIPS quality score. The quality performance threshold requires that a MSSP ACO achieves a quality performance score that is equivalent to or higher than the 30th percentile across all MIPS quality performance category scores. Those MSSP ACOs that fail to meet the quality performance standard will not receive any shared savings, and if applicable, will be assigned maximum risk penalties, regardless of cost performance. CMS has also expanded the conditions under which it can terminate an ACOs participation agreement after a pattern of failing to meet the performance standards.  

Medical Advantage Can Help with APM Reporting 

Understanding the nuances and intricacies of the 2021 QPP Final Rule is crucial to maximizing organization performance and reimbursement. Medical Advantage’s quality experts have over two decades of experience helping healthcare organizations implement best practices, including extensive experience in MACRA and MIPS consulting. Talk to one of our consultants today about how Medical Advantage can help you stay ahead of the curve, master new MIPS requirements, and boost both care quality and profitability at your practice.


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