Med groups to CMS: Include Medicare Advantage patients under Advanced APMs

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Ten healthcare industry groups, including the American Medical Association, have asked CMS to allow Medicare Advantage (MA) patients to count towards the threshold requirements to qualify as an Advanced Alternative Payment Model (APM).

To qualify as an Advanced APM, introduced as part of the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), clinicians have to meet minimum revenue thresholds from certain models or serve a minimum number of beneficiaries in APMs. The final MACRA rule, however, restricts the 2019 and 2020 payment periods to Medicare fee-for-service (FFS) revenue and patients. Those in “other payer” APMs—like MA plans—won’t be able to earn the incentive payment until the 2021 payment year.

“We urge CMS to alter its regulations to allow clinicians’ contracts with MA plans that meet the risk, quality and certified electronic health information technology requirements to be included under the beneficiary count test for the 5 percent Advanced APM bonus in 2019 and 2020,” the groups wrote in a May 1 letter to CMS.

They argued CMS has the power to change the definition of countable patients under the Advanced APM track to include MA enrollees, since the MACRA law didn’t explicitly restrict it to Medicare FFS.

“Had Congress intended to tie the agency's hands under the patient count methodology to restrict countable patients to FFS Medicare beneficiaries, it would have had to so specify,” the letter said. “Since the statute does not include limiting language requiring CMS to only count FFS patients, then the agency has the latitude to interpret this provision to include MA enrollees in the patient count methodology beginning in 2019.”

Simply including Medicare Advantage patients as part of the threshold requirements wouldn’t work, the groups said, since all not all clinicians contracting in a MA plan also participate in an approved APM. They recommend a “step-wise beneficiary count test,” where clinicians are first judged by Medicare FFS revenue and beneficiary thresholds, and if they fail, then MA patient counts are included.

These changes can be done, according to the signatories of the letter, in time for the 2019 payment year.

“CMS finalized three snap shots for qualifying APM participants (QP) determinations with the last snap shot being August 31, 2017, for 2019 payment,” they wrote. “Because CMS will allow for three months’ claims run-out, it notes that the last of these three QP determinations will take place on or around January 1 of the subsequent calendar year (that it, January 2018). If CMS includes a policy change in its expected proposed QPP rule this spring and finalizes the provision by fall, QPs could then attest in the late fall before the January 2018 calculation.”

Besides the AMA, the letter was signed by the Premier Healthcare Alliance, American College of Surgeons, the American Medical Group Association, the American Osteopathic Association, America’s Essential Hospitals, Healthcare Leadership Council, Healthcare Transformation Task Force, Medical Group Management Association and the National Association of ACOs.