Georgia Medicare APM Performance Pathway APP Guide 2026

The APM Performance Pathway (APP) is the streamlined MIPS reporting pathway designed specifically for clinicians who participate in a CMS-recognized Alternative Payment Model, most prominently Shared Savings Program (MSSP) Accountable Care Organizations, but who have not achieved Qualifying APM Participant (QP) status and are therefore MIPS-eligible. For every Georgia clinician practicing through Wellstar's MSSP ACO, Emory's Clinically Integrated Network ACO in MSSP ENHANCED, Piedmont's QCN ACO, Northside's MSSP and ACO REACH entities, Aledade Georgia's multiple MSSP ACOs, Privia Medical Group Georgia's ACO infrastructure, or any of the Georgia FQHC ACO networks, APP is the operational reporting framework that ties ACO Quality performance directly to MIPS scoring and, since the CY 2023 PFS Final Rule, to the MSSP Quality Performance Standard itself.

By Brevy Care Team

The Statutory and Regulatory Foundation

APP exists under the same statutory authority as Traditional MIPS:

• Section 1848(q) of the Social Security Act: MIPS statutory authority, added by Title I, Section 101 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• 42 CFR Part 414, Subpart O: MIPS implementing regulations
• CY 2021 PFS Final Rule: established APP
• CY 2023 PFS Final Rule: tied MSSP Quality Performance Standard to APP Quality performance, finalized eCQM/MIPS CQM transition
• Annual PFS Final Rules: APP refinements

APP was first available for Performance Year 2021. CMS designed APP as the successor to the CMS Web Interface, the legacy ACO Quality reporting mechanism used since the early days of MSSP. The Web Interface allowed ACOs to submit Quality data via a CMS-hosted portal based on sampled beneficiaries. The CMS Web Interface sunset after Performance Year 2022, leaving APP as the sole MIPS reporting pathway for MIPS APM participants.

Who APP Is For (And Who It Is Not For)

APP is the MIPS reporting pathway for MIPS APM participants. To use APP, a clinician must be:

1. Participating in a MIPS APM: Generally an APM Entity recognized by CMS (e.g., MSSP ACO, certain CMMI models)
2. MIPS-eligible: Above low-volume threshold, not in first year of Medicare enrollment
3. Not a QP: Has not achieved Qualifying APM Participant status (which would exempt them from MIPS entirely)

Common APP users:

• MSSP ACO clinicians at all BASIC levels (A, B, C, D, E) and ENHANCED who haven't achieved QP status
• ACO REACH clinicians who haven't achieved QP status
• Other MIPS APM model participants (CMMI models)
• Partial QPs who elect to participate in MIPS

Clinicians who cannot use APP:

• QPs: MIPS-exempt entirely
• Non-APM MIPS clinicians: Must use Traditional MIPS or MVPs
• Clinicians in MIPS APMs whose APM Entity hasn't registered for APP: Edge case; typically APM Entities register

APP Structure: Four Categories with Substantial Pre-Population

The APP final score has four MIPS categories with the same weights as Traditional MIPS:

• Quality
• Cost
• Promoting Interoperability
• Improvement Activities

However, APP pre-populates three of the four categories, leaving Quality as the primary substantive reporting category for ACO submission. This is APP's central simplification.

Quality: The APP Measure Set

APP requires submission of a specific 3-measure ACO Quality measure set:

1. CAHPS for MIPS Survey: Consumer Assessment of Healthcare Providers and Systems patient experience survey, administered by CMS-approved vendors. Covers patient experience with the ACO across multiple composite measures (Getting Timely Care, Communication with Providers, Health Promotion and Education, etc.). Scored via national benchmarks.

2. Risk-Standardized All-Cause Readmission (RSAR) for ACOs: Administrative-claims-calculated measure assessing 30-day all-cause readmission rates following hospital discharge. CMS-developed risk adjustment model. Auto-calculated by CMS.

3. Diabetes HbA1c Poor Control: eCQM/MIPS CQM measure tracking the percentage of patients with diabetes whose HbA1c is above target. Plus additional Quality measures aligned to the APP set in some performance years (e.g., depression remission, controlling high blood pressure, breast cancer screening, colorectal cancer screening).

Submission options:

• eCQM (electronic Clinical Quality Measure): submitted via CEHRT
• MIPS CQM: submitted via approved registry or QCDR
• Medicare CQM: submitted via the CMS Web-based portal (newer hybrid option for ACOs)

The transition from CMS Web Interface to eCQM/MIPS CQM measure submission has been gradual. The CY 2023 PFS Final Rule finalized the sunset of the CMS Web Interface after PY 2022, requiring MSSP ACOs to submit Quality data via eCQM, MIPS CQM, or Medicare CQM under APP.

Promoting Interoperability: Pre-Populated

PI scoring under APP is generally inherited from APM Entity participation. APM Entities are required to use Certified EHR Technology (CEHRT) as a condition of Advanced APM/MIPS APM participation. APP pre-populates PI based on this CEHRT certification. APM Entity-level CEHRT attestation typically satisfies PI for APP submission, simplifying the PI burden substantially compared to Traditional MIPS.

Improvement Activities: Pre-Populated

APP auto-credits Improvement Activities for clinicians whose APM Entity participates in a CMS-recognized APM. The IA category is fundamentally about engaging in care-improvement activities, and participating in an APM (with its required quality measurement, care coordination, and performance accountability) is itself credit-worthy. APP awards full IA credit for APM Entity participation, eliminating the need for separate IA selection and attestation.

Cost: Auto-Weighted

Cost scoring under APP follows the same auto-calculation methodology as Traditional MIPS (TPCC, MSPB-C, EBCMs from administrative claims). For ACO participants, Cost attribution often produces measures with sufficient case volume given ACO size. If case minimums aren't met for any Cost measures, Cost weight is reweighted to other categories.

APP and the MSSP Quality Performance Standard

The CY 2023 PFS Final Rule finalized a major change tying APP Quality performance directly to the MSSP Quality Performance Standard:

• MSSP ACOs must meet the MSSP Quality Performance Standard to share in any savings or avoid maximum loss penalties
• The MSSP Quality Performance Standard is defined as performing at or above a specified quality percentile threshold on the APP Quality measure set (a Health Equity Adjustment can lower this threshold)
• ACOs that meet the standard share in savings per their track participation level
• ACOs that fail the standard receive zero savings (BASIC A/B) or reduced/zero savings and potential loss exposure (BASIC C/D/E/ENHANCED)

This linkage means APP Quality reporting is not just a MIPS submission. It is the core MSSP performance assessment. Georgia MSSP ACOs that perform poorly on APP Quality face both:

• MIPS payment adjustment (negative if Final Score falls below the performance threshold): affects every Part B claim
• MSSP savings forfeiture (failure to meet the quality performance standard): affects ACO shared savings cash flow

This dual consequence makes APP Quality performance the most consequential quality reporting Georgia ACO clinicians do.

Health Equity Benchmark Adjustment

Under the CY 2023 PFS Final Rule, MSSP introduced a Health Equity Benchmark Adjustment that can lower the Quality Performance Standard for ACOs serving substantial underserved populations. The adjustment is calculated based on Area Deprivation Index (ADI) scores and dual-eligible enrollment in the ACO's attributed population. ACOs serving high-ADI/dual-eligible-heavy populations face a lower effective Quality Performance Standard, reflecting the challenges of quality measurement in disadvantaged populations.

For Georgia rural ACOs and Georgia ACOs with substantial FQHC participation (which typically have high ADI scores), the Health Equity Adjustment provides meaningful relief in the MSSP Quality Performance Standard calculation.

APP versus Traditional MIPS versus MVPs

Three streamlined MIPS reporting paths exist:

Key distinctions:

• APP is restricted to MIPS APM participants. Traditional MIPS and MVPs are not.
• APP has the fewest substantive submission obligations: only Quality requires real reporting
• APP and MVPs cannot be combined. APM participants choose APP or Traditional MIPS, not MVPs.
• MSSP ACOs essentially must use APP: Quality Performance Standard tied to APP Quality

APP Reporting Mechanics

Reporting Level

APP reporting occurs at the APM Entity level. The ACO (or other APM Entity) submits Quality data on behalf of all participating clinicians. Individual clinician submission is generally not used for APP.

Submission Identifier

APM Entities are identified by their CMS-assigned APM Entity Identifier. ACO Quality submissions tie to this identifier rather than to individual TINs or NPIs.

Submission Window

The MIPS submission window opens in January of the year following the Performance Year and closes in the spring. For current submission window dates, check the QPP Service Center at qpp.cms.gov.

Submission Methods

• Via approved registries / Qualified Clinical Data Registries (QCDRs)
• Via certified EHR technology (CEHRT) for eCQM submissions
• Via the CMS Web-based portal for Medicare CQM submissions

Required Volume

For each Quality measure: data at the case minimum and data completeness threshold specified by CMS in the applicable year's program requirements.

Subgroup Eligibility under APP

The Subgroup reporting innovation from the MVP framework does extend to APP in a limited way. CMS has signaled and partially finalized Subgroup-eligible APP reporting for multi-specialty groups within ACOs. The specific operational rules are still evolving via annual PFS Final Rule rulemaking. For most Georgia MSSP ACOs, APM Entity-level reporting remains the default and most common approach.

Final Score, Performance Threshold, and Payment Adjustment

APP-submitted clinicians receive a Final Score of 0 to 100 calculated using the same MIPS formula combining Quality, Cost, Promoting Interoperability, and Improvement Activities. The Performance Threshold and maximum payment adjustment are the same as Traditional MIPS. The budget-neutral methodology remains in place.

A typical APP submission with adequate Quality performance produces:

• Quality score: Depends on ACO Quality measure performance relative to national benchmarks
• PI score: High (often near max) given APM Entity CEHRT participation
• IA score: Full credit for APM Entity participation
• Cost score: Variable based on attribution

Because PI, IA, and Cost categories are simplified/pre-populated, APP Final Score is heavily influenced by Quality performance. ACO Quality performance therefore drives both MIPS adjustment (via APP Final Score) and MSSP Quality Performance Standard (via APP Quality percentile).

eCQM, MIPS CQM, and Medicare CQM Transition

The CMS Web Interface sunset after PY 2022 required ACOs to transition to electronic measure submission methods. Three options exist:

eCQM (Electronic Clinical Quality Measure)

• Submitted via CEHRT (ONC-certified EHR)
• Data extracted from EHR clinical workflow
• Most aligned with HIT-mature practices
• Requires CEHRT capable of eCQM generation

MIPS CQM

• Submitted via approved registry or QCDR
• Registry receives data from practice
• Calculation done at registry level
• Bridge option for practices without robust CEHRT eCQM capability

Medicare CQM

• Submitted via CMS Web-based portal
• CMS-hosted system for ACO Quality
• Hybrid option introduced as Web Interface successor
• Provides Web-Interface-like submission experience

ACOs choose one method per Quality measure but can mix methods across measures. The transition has been challenging for some ACOs, particularly smaller ACOs and FQHC-based ACOs with less HIT infrastructure, leading to phased adoption supported by CMS technical assistance.

Georgia Provider Implications

Wellstar Health System (MSSP)

Wellstar's MSSP ACO uses APP for Quality reporting. Wellstar's CEHRT (Epic) enables eCQM submission for the APP Quality set. Wellstar's clinicians who are not QPs are subject to MIPS adjustment via APP Final Score.

Emory Healthcare Network (MSSP ENHANCED)

Emory CIN ACO operates in MSSP ENHANCED, an Advanced APM. Many Emory clinicians achieve QP status (exempt from MIPS). Those who don't (Partial QPs electing MIPS, or clinicians below thresholds) report via APP. Emory's eCQM submission via Epic is operationally smooth.

Piedmont QCN (MSSP)

Piedmont Quality Care Network participates in MSSP. APP reporting handles Quality submission for non-QP Piedmont clinicians.

Northside Hospital System (MSSP, ACO REACH)

Northside's dual participation in MSSP and ACO REACH means APP applies to non-QP clinicians in either model. APM Entity-level submission via Northside's Epic CEHRT.

Aledade Georgia ACOs (MSSP BASIC A-E and ENHANCED)

Aledade operates multiple MSSP ACOs across Georgia. ACOs in BASIC C/D/E and ENHANCED produce QP status for participating clinicians; BASIC A/B ACOs are MIPS APMs. Both QP and non-QP Aledade clinicians benefit from Aledade's centralized Quality reporting infrastructure that submits via APP.

Privia Medical Group Georgia

Privia operates ACO infrastructure across Georgia. Privia clinicians participating in MIPS APM ACOs report via APP. Privia's centralized Quality reporting infrastructure manages APP submission.

Georgia FQHC ACO Networks

Georgia FQHCs participating in MSSP via ACO-as-a-Service networks (Aledade, Privia, others) report Quality via APP at the APM Entity level. FQHC PPS services remain not subject to MIPS regardless, but Part B Professional Services billed by FQHC clinicians factor into APP Final Score for non-QPs.

Palmetto GBA Part A/B MAC Jurisdiction J

Palmetto GBA processes Georgia Medicare Part B claims and applies MIPS adjustments per APP Final Score for non-QP Georgia ACO clinicians.

Worked Examples

Example 1: Fulton 70, Emory CIN APP Reporting for Partial QP

Dr. Patel, age 70, internal medicine at Emory Decatur. Emory CIN ACO participates in MSSP ENHANCED. PY 2024:

• Dr. Patel's Part B Professional Services 65% through MSSP ENHANCED (below 75% QP threshold)
• Partial QP status: Payment-amount 50%-75% range
• Dr. Patel elects to participate in MIPS (not exempt without IP)
• Reports via APP at Emory CIN APM Entity level
• APP Quality: CAHPS for MIPS, Risk-Standardized Readmission, Diabetes HbA1c Poor Control, and additional eCQMs via Epic
• APP Quality score: 28/30
• APP PI: pre-populated, near maximum
• APP IA: full credit for APM Entity participation
• APP Cost: variable (TPCC + MSPB attribution)
• Final Score: 90 out of 100

Example 2: DeKalb 75, Emory Cardiology Partial QP APP

Dr. Hoang, age 75, interventional cardiology at Emory Saint Joseph's. Partial QP, elects MIPS via APP:

• Reports via Emory CIN APM Entity APP
• Same APP Quality measure set as Dr. Patel above
• Quality score: 27/30 (Emory CIN aggregate)
• PI: near maximum
• IA: full credit
• Cost: variable (AMI EBCM attribution for cardiology)
• Final Score: 89 out of 100

Example 3: Cobb 68, Aledade BASIC A APP

Dr. Williams, age 68, leads three-physician family medicine group in Marietta. Practice participates in Aledade Georgia MSSP BASIC Level A ACO (MIPS APM, NOT Advanced APM, upside-only):

• BASIC A is not Advanced APM, so no QP status available
• All Dr. Williams' practice clinicians are MIPS-eligible MIPS APM participants
• Reports via APP at Aledade BASIC A APM Entity level
• Aledade's centralized Quality reporting submits APP measures
• Final Score: 81 out of 100 (small practice double-weighted IA and Aledade Quality performance)

Example 4: Worth County 72, Albany Area FQHC APP

Albany Area Primary Health Care FQHC participates in Aledade Georgia MSSP BASIC E ACO (Advanced APM). Dr. Johnson, age 72, achieves QP status and is MIPS-exempt. Dr. Smith at the same FQHC has lower Advanced APM Part B Professional Services attribution (some Smith services billed outside Aledade attribution):

• Dr. Smith Partial QP, elects MIPS via APP
• FQHC PPS-paid services NOT subject to MIPS
• Part B Professional Services subject to APP
• APP Quality at Aledade Georgia BASIC E APM Entity level (high-performing ACO)
• Final Score: 87 out of 100
• Health Equity Adjustment helps Aledade ACO's MSSP Quality Performance Standard given high-ADI Worth County population

Example 5: Bibb 80, Piedmont QCN APP

Dr. Chen, age 80, orthopedic surgeon at Piedmont Macon. Piedmont QCN participates in MSSP BASIC Level C (Advanced APM). Dr. Chen's procedural revenue means most Part B Professional Services attribute to outside-ACO procedures, resulting in Partial QP status:

• Reports via Piedmont QCN APM Entity APP
• APP Quality at Piedmont QCN level
• Final Score: 78 out of 100

Example 6: Hall 67, Northside MSSP Cardiology APP

Dr. Singh, age 67, cardiologist at Northside Hospital Gainesville. Northside MSSP ACO and Northside ACO REACH operate simultaneously:

• Dr. Singh participates in Northside MSSP at BASIC Level D (Advanced APM)
• Northside MSSP attribution provides 55% Part B Professional Services through Advanced APM
• Partial QP status, elects MIPS via APP
• APP Quality at Northside MSSP APM Entity level
• Final Score: 84 out of 100

Best Practices for Georgia APP-Reporting ACOs

1. Coordinate with APM Entity early: Quality reporting via APP requires APM Entity-level submission infrastructure
2. Plan eCQM/MIPS CQM/Medicare CQM submission method per measure: Choose based on CEHRT capability and registry options
3. Engage CEHRT vendor on eCQM capability: Confirm vendor supports the APP Quality measure set
4. Monitor Health Equity Adjustment eligibility: High-ADI/dual-eligible ACO populations may qualify for adjusted MSSP Quality Performance Standard
5. Coordinate with MSSP Quality Performance Standard: APP Quality drives both MIPS Final Score and MSSP savings eligibility
6. Submit within the MIPS submission window: Check qpp.cms.gov for current-year deadline
7. Verify APP eligibility for each clinician: QPs are MIPS-exempt and don't need APP; non-QPs in MIPS APM participate via APP
8. Track Partial QP elections: Partial QPs choosing to participate in MIPS must report via APP (not Traditional MIPS)
9. Engage Acentra Health QIO: Free APP technical assistance available for Georgia providers through the QPP Service Center
10. Document APM Entity participation lists: Ensure all participating clinicians are correctly listed for APP attribution
11. Map Quality measures to existing reporting: Many ACOs already track APP measures; APP consolidates rather than introducing new measures
12. Coordinate with Cost measure attribution: TPCC and MSPB-C attribution at APM Entity level affects APP Final Score
13. Monitor APP performance feedback: Review July CMS performance feedback; submit Targeted Review within 60 days
14. Train ACO staff on APP terminology: eCQM vs. MIPS CQM vs. Medicare CQM; APP vs. Traditional MIPS vs. MVPs

Common APP Issues for Georgia ACOs

1. Missing CMS Web Interface sunset: Some ACOs unprepared for eCQM/MIPS CQM transition after PY 2022
2. CEHRT eCQM capability gaps: Older CEHRT versions may not generate APP eCQMs correctly
3. Quality measure data completeness: Data completeness threshold must be met per measure
4. Wrong submission method: Choosing eCQM when MIPS CQM would be easier, or vice versa
5. APM Entity participation list errors: Missing NPIs from participation list means missing APP attribution
6. Confusing APP with APM Incentive Payment: APP is MIPS reporting path; APM IP is the QP payment benefit
7. Missing MSSP Quality Performance Standard linkage: Treating APP Quality as just MIPS, missing MSSP shared savings impact
8. Cost measure case minimum issues: APM Entity attribution may not meet TPCC or MSPB-C minimums in small ACOs
9. Health Equity Adjustment underutilized: ACOs not pursuing Health Equity Adjustment when eligible
10. Submission window missed: Submit before the MIPS submission deadline; check qpp.cms.gov for current dates
11. Mid-year APM Entity changes: Joining/leaving APM Entity mid-year complicates APP attribution
12. Treating Subgroup reporting as available: Subgroup APP reporting is still evolving; default is APM Entity level
13. Confusing APP and MVP eligibility: APP for MIPS APM participants; MVP for non-APM specialty; cannot combine
14. MIPS Adjustment surprise: Two-year offset means PY 2024 APP score affects 2026 cash flow

Resources and Contacts

For APP questions:

• QPP Service Center: qpp.cms.gov
• Medicare: 1-800-MEDICARE (1-800-633-4227)
• Palmetto GBA Part A/B MAC Jurisdiction J: palmettogba.com
• Acentra Health QIO (Georgia): Free APP technical assistance; contact through qpp.cms.gov
• GeorgiaCares SHIP: Free Medicare counseling for Georgia beneficiaries
• CMS Innovation Center: Resources on CMMI APM models
• Medical Association of Georgia (MAG): mag.org
• National Association of ACOs (NAACOS): naacos.com
• MSSP Program Resources: cms.gov/medicare/shared-savings-program

Why APP Matters for Georgia ACO Participants

The APM Performance Pathway is the operational reporting framework for every Georgia Medicare MSSP and ACO REACH clinician who is MIPS-eligible but not yet a QP. For Atlanta primary care practices in Emory CIN's MSSP ENHANCED, for Marietta family medicine groups in Aledade Georgia's MSSP BASIC E, for rural FQHC clinicians in Aledade BASIC E or Privia ACOs, for Macon orthopedic surgeons in Piedmont QCN's MSSP BASIC C, for Northside Gainesville cardiology in Northside's MSSP and ACO REACH entities: APP is the MIPS reporting path that ties ACO Quality performance to MIPS payment adjustment and to the MSSP Quality Performance Standard that governs shared savings eligibility. The CMS Web Interface sunset after PY 2022 made APP the sole streamlined MSSP Quality reporting framework. The CY 2023 PFS Final Rule tied the MSSP Quality Performance Standard directly to APP Quality. The Health Equity Adjustment introduced relief for ACOs serving underserved Georgia populations. Together these regulatory steps have made APP the single most consequential MIPS reporting framework in the value-based care landscape, and understanding APP is essential for every Georgia ACO administrator, clinician, and Quality reporting team navigating the modern Quality Payment Program established by MACRA and operationalized through Section 1848(q) of the Social Security Act.

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