Understanding MIPS Requirements for ACO REACH Participants | Ask Dr. Mingle
In this episode of Ask Dr. Mingle, Dr. Dan Mingle explains when ACO REACH participants might still have a MIPS reporting requirement. Then, Dr. Mingle explains what those MIPS requirements could be for individual providers.
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Question One: Understanding Possible MIPS Requirements for ACO REACH
Daphne asks: “Our practice is participating in ACO REACH. Do our providers have any MIPS requirements?”
Great question, Daphne.
And the answer is definitive and clear: Yes and no.
Let me attempt to make it definitive and clear.
First: ACO REACH is an Advanced Alternative Payment Model.
It has substantial, way more than nominal, upside and downside risk. Your qualified participants in REACH, as in any aAPM, have no MIPS obligations.
But Qualified Participant Status is not a given. It depends on hitting the benchmarks of beneficiary participation, either by the percentage of billing or the percentage of patient counts:
- Each provider who meets or exceeds the volume benchmarks is considered a Qualified Participant and has no MIPS obligations. They can’t even opt in.
- Providers who meet a lower benchmark are considered Partial QPs and can choose whether or not to participate in MIPS. Of course, you would like to base that decision on whether the provider will earn a positive or negative adjustment. Mingle Health can help you with that.
Any of your providers who do not hit either ACO volume benchmark will have a MIPS obligation. And, of course, we can help you with that as well.
Your providers could receive the total -9% adjustment if they do not submit.
Second: A practice participating in a REACH ACO does not immediately include all its providers.
The practice must be enrolled as a participant.
Each provider also has to be individually enrolled as a participant.
Any provider not enrolled as a participant will have a MIPS obligation.
Third, there are two different levels of provider REACH involvement.
- Subject to beneficiary alignment, capitated payment, can be Qualified Participants. Typically these will be your primary care providers. MIPS obligation is dependent on QP status.
- Not subject to alignment, and they might be capitated. Preferred REACH providers cannot be QPs, and they are subject to MIPS unless they have another exception, like the low volume threshold.
It’s essential to know each provider’s participation (QP) status.
Medicare determines QP status quarterly, and they post each quarter’s results on the qpp.cms.gov website.
Question Two: MIPS Requirements for ACO REACH Providers Explained
Daphne also asks: “I understand there are several reasons why providers in our REACH participating practice might need to submit MIPS. What are the MIPS requirements for those providers?”
It won’t work the same way in REACH as in the MSSP.
In the MSSP, before the APP, the Web Interface quality submissions covered both MIPS quality requirements and the MSSP APM quality requirements.
Now under the APP, and during the transition, APP submissions still function in the same way. Non-QPs participating in the MSSP can get MIPS quality credit for the MSSP quality submission.
But under REACH, there is no quality submission. Medicare calculates four administrative claims measures for REACH ACOs, and the CAHPS survey is required.
In the last question, I described when REACH-involved providers will have a MIPS obligation:
- Your practice providers who are not participants in the REACH ACO.
- Your practice providers who are only preferred providers in the REACH ACO – these will likely be your specialty providers.
- Your participating providers who are not Qualified Participants or partial QPs.
- Your partial QP providers who elect to participate in MIPS.
Your safe assumption would be that all four of these categories will need a complete MIPS submission to avoid negative adjustments. I say “safe” to “mean worst case scenario.”
As a new program, Medicare will recognize holes in the rules and unintended consequences they will correct on the fly. There may already be rulings published that I have not yet seen or regulations that are yet to be published that will change these expectations. If you run across anything, I would be grateful if you would share it with me.
Many exceptions to these rules may depend highly on your specific circumstances and the conditions of your particular REACH ACO contract with CMS.
If you engage us, we can help you sort through the myriad of questions and circumstances and seek anticipatory guidance from Medicare.
Finally, here are my current expectations of possible MIPS requirements for ACO REACH participants, by performance category:
Cost: I expect your non-REACH providers to be subject to the usual MIPS Cost measures that Medicare will calculate from claims.
Quality: The REACH quality measures that allow you to collect your REACH quality withhold are not MIPS measures. The one possible exception is the CAHPS survey. Plan on a traditional or an MVP MIPS submission for your non-QPs.
Improvement Activities: I expect your partial QPs and non-QP REACH participating providers to get full IA credit for REACH participation. I expect your REACH preferred and non-participating providers to need Improvement Activity submissions.
Promoting Interoperability: All providers subject to MIPS will need a Promoting Interoperability submission.
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As MIPS becomes more difficult, it's crucial to have a plan in place. We've made a guide that provides an overview of 2023 MIPS requirements and changes to help you and your organization find success in the 2023 Performance Year.