CMS Ambulatory Specialty Model (ASM) FAQs for Heart Failure Providers

The Ambulatory Specialty Model (ASM) is a mandatory Medicare specialty payment model designed to change how chronic disease is managed in outpatient settings. For heart failure providers, the Ambulatory Specialty Model shifts expectations away from episodic, visit-driven care and toward longitudinal accountability for disease stability, utilization patterns, and total cost of care. The model emphasizes earlier intervention, consistent physiologic monitoring, and prevention of avoidable hospitalizations that directly influence quality performance and financial outcomes.

Beginning in 2027, selected specialists who routinely manage heart failure patients in outpatient settings will be required to participate in the Ambulatory Specialty Model across designated regions. The ASM model spans five performance years, which means performance expectations compound over time rather than resetting annually. Heart failure practices that approach the Ambulatory Specialty Model as a short-term compliance exercise are likely to struggle, while those that invest in sustained care management infrastructure are better positioned for long-term success.

Answers provided to the questions below about the Ambulatory Specialty Model should help explain how ASM applies to heart failure care and how remote patient monitoring (RPM) supports performance under the model.

Q: Is participation in the CMS Ambulatory Specialty Model mandatory for heart failure providers beginning in 2027?

Participation in the Ambulatory Specialty Model is mandatory for selected heart failure clinicians and practices located in designated geographic regions. Once CMS identifies a clinician or practice for inclusion, participation is required for the full duration of the model and cannot be declined. This ASM participation requirement applies regardless of prior experience with value-based programs or performance in other Medicare initiatives. Note: CMS released the selected geographic areas and a preliminary list of participants in early 2026, with the final participant list expected to be published in July 2026.

The mandatory nature of ASM reflects CMS's intent to move specialty care, particularly heart failure care (as well as low back pain care), into a more accountable framework focused on prevention, longitudinal management, and utilization control. Rather than allowing specialists to selectively engage in value-based care, ASM establishes these expectations as a baseline for participation in Medicare fee-for-service reimbursement.

Q: How does CMS select clinicians and practices for inclusion in the Ambulatory Specialty Model for heart failure?

CMS selects participants in the Ambulatory Specialty Model through retrospective analysis of Medicare claims data rather than a voluntary enrollment process. Clinicians and practices are identified based on historical outpatient care patterns for beneficiaries with heart failure, using objective utilization and billing data.

Selection factors include specialty designation, the volume of attributed heart failure patients, and practice location within CMS-designated regions (download a spreadsheet identifying the mandatory geographic areas here). Clinicians do not submit applications, and inclusion is not influenced by stated interest or readiness.

Since the selection process is claims-driven, practices may not fully recognize their exposure to ASM until they receive formal notification. This creates a strong incentive for cardiology and specialty practices with meaningful heart failure populations to assess attribution risk and operational preparedness in advance of the model start date.

Q: Which quality measures in the Ambulatory Specialty Model most directly impact payment adjustments for heart failure providers?

Quality measures tied to physiologic control and utilization outcomes have the greatest impact on payment adjustments under the Ambulatory Specialty Model. For heart failure providers, blood pressure control stands out because it directly influences disease progression, symptom burden, and the likelihood of acute events. Poor control increases the risk of exacerbations that often result in emergency department visits or inpatient admissions, both of which negatively affect quality and cost performance.

Measures related to avoidable inpatient admissions, readmissions, and emergency department utilization also influence financial outcomes. These measures are designed to reflect whether heart failure is being managed proactively or allowed to deteriorate to the point of requiring acute care. Under ASM, utilization outcomes are not viewed as isolated events but as indicators of how effectively outpatient management is functioning over time.

Operationally, these measures place new emphasis on consistent monitoring, timely follow-up, and documentation practices. Performance is not determined solely by clinical intent or treatment plans, but by whether measurable outcomes are captured reliably across the attributed population. Practices that lack standardized monitoring workflows or depend on sporadic data collection are more likely to see performance scores that underrepresent the care being delivered.

Q: How do Ambulatory Specialty Model payment bonuses and penalties compare to MIPS and other quality programs?

The Ambulatory Specialty Model introduces a higher level of financial exposure than MIPS and many other legacy quality programs. MIPS relies on composite scoring across multiple categories and typically results in modest payment adjustments that are spread broadly across the clinician population.

In contrast, ASM directly links specialty-specific quality performance and total cost of care to Medicare payment adjustments. This creates a clearer and more immediate connection between how heart failure care is delivered and how clinicians are reimbursed.

For heart failure practices, this structure increases both upside opportunity and downside risk over a multi-year period. Sustained improvements in monitoring, care coordination, and utilization management are more likely to influence financial outcomes than isolated performance gains.

Q: What is the blood pressure control quality measure in the Ambulatory Specialty Model, and how is performance calculated for heart failure patients?

The blood pressure control measure in the Ambulatory Specialty Model evaluates whether attributed heart failure patients maintain readings below defined thresholds during the performance period. CMS calculates performance by identifying eligible patients, capturing valid blood pressure measurements, and determining the percentage of patients who meet control criteria based on their most recent qualifying reading.

Because this measure is numerator and denominator based, patients without a documented blood pressure reading during the measurement window still count against performance. This means that gaps in data collection can significantly lower scores, even when patients are clinically stable or well-managed. Infrequent office visits, missed follow-ups, or reliance on episodic encounters increase the likelihood of underreporting.

For heart failure providers, blood pressure control under ASM is as much a measurement challenge as a clinical one. Reliable performance depends on having consistent processes to capture readings across the patient population, not just during scheduled visits. Practices that treat blood pressure measurement as an occasional task rather than an ongoing process may struggle to reflect true disease control in their quality results.

Q: Can remote patient monitoring be used to meet blood pressure reporting and quality requirements under the Ambulatory Specialty Model?

Remote patient monitoring can be used to support blood pressure reporting and quality requirements under the Ambulatory Specialty Model when compliant blood pressure devices, patient attribution, and documentation workflows are properly established. RPM enables frequent collection of blood pressure readings in the home setting, creating a longitudinal data stream rather than isolated snapshots.

This approach improves data completeness and timeliness, which are critical for numerator and denominator based quality measures. Instead of relying on a single office visit to generate a qualifying reading, practices can capture multiple measurements over time, increasing the likelihood that performance reflects actual patient control.

For heart failure populations, RPM also supports earlier identification of trends that may indicate worsening status. Rising blood pressure, increasing variability, or sustained elevations can prompt earlier clinical intervention before symptoms escalate. This aligns directly with ASM's emphasis on upstream management and prevention, while also strengthening quality measurement reliability.

Q: Is RPM necessary for heart failure practices to succeed financially under the Ambulatory Specialty Model?

Remote patient monitoring is not explicitly required by the Ambulatory Specialty Model, but many heart failure practices will find it difficult to achieve consistent financial success without it. Practices that rely primarily on periodic office visits often lack visibility into patient status between encounters, which delays intervention and increases the likelihood of acute events.

Without RPM, gaps in data collection can lead to underperformance on quality measures such as blood pressure control, even when treatment plans are appropriate. These gaps also limit the practice's ability to demonstrate effective longitudinal management, which is central to ASM's design. Over time, this can translate into missed shared savings opportunities or increased exposure to payment reductions.

Across a five-year model period, the cumulative effect of delayed intervention, incomplete data, and avoidable utilization becomes more pronounced. Remote patient monitoring helps mitigate these risks by supporting proactive management, improving measurement reliability, and enabling care teams to act earlier. For many heart failure practices, RPM functions less as an optional add-on and more as enabling infrastructure for sustained ASM performance.

Q: How does the Ambulatory Specialty Model cost score work for heart failure participants?

The cost score under the Ambulatory Specialty Model evaluates total Medicare spending for attributed heart failure patients relative to a risk-adjusted benchmark. This includes inpatient admissions, emergency department visits, post-acute care, and related outpatient services tied to heart failure management.

CMS compares actual spending to the benchmark to determine whether a practice generates savings or excess costs. Quality performance thresholds must also be met to qualify for shared savings, linking cost control directly to care quality.

Since inpatient utilization represents a large share of total spending for heart failure populations, strategies that reduce hospitalizations and readmissions have a disproportionate impact on cost performance under ASM.

Q: Why is weight monitoring important for reducing hospitalizations and readmissions under the Ambulatory Specialty Model?

Weight monitoring is a foundational component of heart failure management because sudden increases in weight often signal fluid retention before symptoms become severe. Even modest changes can precede decompensation that leads to emergency department visits or hospital admissions.

Routine weight monitoring allows clinicians to intervene earlier through medication adjustments, patient outreach, or changes to care plans. Earlier intervention reduces the likelihood that worsening symptoms progress to acute events.

Under the Ambulatory Specialty Model, preventing avoidable hospitalizations improves both quality scores and cost performance. As a result, consistent weight monitoring is a high-impact strategy for heart failure practices seeking to succeed under the model.

Preparing Heart Failure Practices for Success Under the Ambulatory Specialty Model

As heart failure care moves into mandatory value-based models, technology-enabled monitoring and proactive management are no longer optional. Prevounce helps practices prepare for and succeed under the Ambulatory Specialty Model through scalable remote patient monitoring, reliable physiologic data capture, care management services, and workflows designed for long-term accountability.

Learn how Prevounce can support your ASM strategy and help your practice improve outcomes, manage cost, and navigate the future of value-based specialty care with confidence and success.

* Disclaimer: The above information is for informational purposes only and does not constitute legal or other professional advice. Billing and coding requirements — especially in the telehealth space — can change and be reinterpreted often. You should always consult an attorney and/or medical billing professional prior to submitting claims for services to ensure that all requirements are met.