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ACO REACH vs. MSSP ACO Requirements, MIPS Submissions for ACO High-Performers, and more!

In this week’s episode, Dr. Dan Mingle shares some insight into the differences between MSSP ACOs and REACH ACOs, explains when it may make sense for high-performing ACO participants to make a MIPS submission, and clarifies how to understand data completeness performance in MIPS reports.

Click play to listen to this episode now:

Question One: Data Completeness in MIPS Reports

Sheryl asks: “I still can’t wrap my mind around the concept of data completeness. I understand that it means we have to report on 70% of all the patients that fall into the denominator. But can’t that be derived from looking at a MIPS report that the vendor supplies? Would this not be the percentage that is determined from the denominator/numerator calculation? And, is this something that the vendor has to do behind the scenes or is this something that we can determine when looking at MIPS reports?”

You are right; you should find it in your vendor’s MIPS reports. But to be accurate in the vendor reports, it has to come from the data your practice has provided to the vendor.

The denominator should be a complete count of every patient seen during the performance period eligible for the measure. There should be four numerators generated against that denominator. As a check, the sum of the four numerators should equal the denominator.

An explanation of each numerator:

  • The first numerator is the count of patients qualifying for a valid exclusion.
  • The second numerator is the count of patients qualifying for “Performance Met.”
  • The third numerator is the count of patients for whom “Performance Not Met.”
  • And finally, the fourth numerator is a count of patients for whom data is unavailable or “Not Reported.”
    • The inverse of the “Not Reported” rate is the “Reporting Rate.”
    • It is this “Reporting Rate” that has to be 70% or above.

For these numbers to be credible and survive Medicare audit, the denominator count of eligible patients needs to be accurate, even if clinical performance data is incomplete.

Luckily, we at Mingle Health find that the visit data from practice management systems is almost universally available from practices. It is usually possible to source claims data from all practices in an organization and to calculate a credible denominator.

Access to clinical data is more variable. It is all accessible one way or another, but access can be cost-prohibitive.

Today, Medicare is satisfied if we expend the time, effort, and money to collect 70% of the clinical data, and they forgive us the final 30% when it is just too hard to access.

You can find additional information on Data Completeness in this clip from a previous episode.

Question Two: MIPS Submissions for High-Performers

Janet asks: “Does it make sense to recommend to our higher performing ACO participants to make a MIPS quality submission in addition to the APM Performance Pathway submission the ACO will make on their behalf? Might they be able to collect both a positive MIPS adjustment on top of the 5% APM bonus?”

A note from Dr. Mingle on a recent revision to his answer to Janet’s question:

  • Dr. Mingle mentions that he stands by his explanation below but needs to include new legislation from December 2022.
    • The Advanced APM Consolidated Appropriations Act established one more year of the advanced APM incentive.
    • The incentive is reduced for this additional year from 5% to 3.5%.
    • It’s available only to Qualified Participants in an advanced APM in 2023.
      • It will add 3.5% to all Medicare payments to qualified participants for services provided in 2025.
      • This change fills a gap. In 2026, Qualified Participants will get more favorable payments through Medicare’s Physician Fee Schedule.
      • Before this legislation, 2025 would have been the only year Qualified Participants received no incentive in the lapse between the QP 5% incentive and the favorable PFS conversion rates.

It might make sense to recommend some of your high-performing practices to make a separate MIPS submission, but not for the reason you think.

All Medicare Shared Savings Program (MSSP) ACOs are now subject to the APM Performance Pathway (APP). There is a quality requirement for the APP, and your MSSP ACO is choosing whether it will meet that requirement with the Web Interface, eCQMs, or MIPS CQMs.

But that APP quality submission is already doing double duty:

  • The ACO’s APP quality submission meets the quality requirement of the MSSP.
  • It also serves as a MIPS quality submission if your ACO participants need it.

An MSSP participant can qualify for a MIPS adjustment or the 5% APM participation bonus, but no one is eligible for both.

The Medicare Shared Savings Program (MSSP) is an Alternative Payment Model (APM). MSSPs come in two flavors: advanced and not advanced.

Whether it is advanced relates to the level of risk agreed to in the contract:

  • A low-risk MSSP contract is considered a MIPS APM.
  • MIPS APMs do not collect the 5% APM bonus. But they are eligible for MIPS adjustments, whether positive or negative.
  • The MSSP is an advanced APM if it will share in any savings AND is liable for a share of any loss.
  • Qualified participants in Advanced APMs are awarded the 5% advanced APM bonus but are not eligible for MIPS adjustments.
  • Partially Qualified participants are not eligible for the advanced APM bonus and can choose whether or not they participate in MIPS and are, therefore, subject to MIPS adjustments.
  • Advanced APM participants who do not meet the threshold to be qualified or partially qualified have a MIPS obligation.

Any APM participant who is obligated or chooses to participate in MIPS can consider the APP submission to represent their MIPS quality score.

There is a potential benefit for advising your high-performing practices or providers to make a separate MIPS submission. Medicare will grant the highest applicable quality score to most providers with multiple submissions.

Your APP submission will represent an average of performance across the entire MSSP ACO. For your providers who are above average, making an additional submission of individual or group practice data could give them a higher MIPS score and, therefore, a higher MIPS adjustment.

The extra submission is not applicable if they are qualified participants in your advanced MSSP ACO.

But it is a valid consideration for any of your high-performing providers who have a MIPS obligation or choose to have one.

Question Three: REACH ACO and MSSP ACO

Brad asks: “I’ve noticed that you seem to use the terms ‘ACO’ and ‘MSSP’ interchangeably. Are the requirements the same between the two? And do REACH ACOs qualify for the Advance Investment Payments that other ACOs receive?”

And my apologies for being inconsistent and confusing in my use of terms.

You are right:

  • “ACO” and “MSSP” are related but not synonymous.
    • All MSSP participants are in ACOs. But not all ACOs are MSSPs.
  • As you point out, REACH is also an ACO, but the requirements are not the same as an MSSP.
  • There have been other varieties of ACO, but I think those two are the only ones currently operating within the Medicare system.

Advance Investment Payments are a new feature offered to new low-revenue MSSP ACOs. These payments do not exist in the current operational rendition of the REACH ACO model.

Question Three: REACH ACO and QP Status

Brad asks: “Can you help clarify what an ACO REACH organization has to do for reporting in Performance Year 2023 under two scenarios: 1) the ACO achieves full or partial QP status, and 2) the ACO does not achieve full or partial QP status?”

I’d urge you to review your REACH contract to be sure.

My understanding is that quality measurement for REACH ACO is entirely done by Medicare from administrative claims. CMS doesn’t require a submission from a REACH ACO.

If yours is an Advanced ACO and participants achieve QP or Partial QP status, no further quality reporting is required. Though Partial QPs can decide to participate in MIPS, in which case they have a standard MIPS quality reporting obligation.

If your REACH ACO is a MIPS APM or your participants do not achieve at least a partial QP designation, they also have a standard MIPS quality reporting obligation.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

Want to learn more about the APM Performance Pathway (APP)?

As the Web Interface sunsets, ACOs must prepare to transition into the APM Performance Pathway (APP) reporting method by Performance Year 2025. For many ACOs, this task is daunting - with data challenges, technical hurdles, and a completely new reporting workflow. To help with this, we've created the APM Performance Pathway Checklist - a two-page resource to assist your organization in understanding and preparing for this challenge.

Access the Checklist
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