Navigating MIPS in a REACH ACO: Risks, Recommendations, and Success Strategies
In this episode of Ask Dr. Mingle, Dr. Dan Mingle explains when ACO REACH participants may have MIPS liabilities. Later, he offers his recommendations for addressing MIPS in ACO REACH.
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Question One: Explaining MIPS in a REACH ACO
Katherine asks: “My practice is participating in a REACH ACO. I understand that there may be MIPS liabilities for some of our providers. Can you explain that?”
There are three pathways by which a provider in your practice might have a MIPS liability.
Under REACH ACO rules, NPI providers working and billing under the same TIN practice are not necessarily all participating in the REACH ACO. Participation is an offer made to individual NPI providers by the ACO and accepted or not by the individual provider. Your practice might have a mix.
MIPS liabilities for your providers participating in the REACH ACO depend on the rules and thresholds for Qualified Participant or “QP” status.
With this in mind, there are three pathways by which a provider in your practice might have a MIPS liability.
The first pathway is non-participation.
All providers in your practice who are not participating in the ACO will have a MIPS liability unless there is an exception for which they qualify, like the new provider exception or the low volume exclusion.
The second pathway is Qualified Participant or “QP” status.
Providers participating in the REACH ACO will be evaluated for their volume, sorting them into three categories: Qualified Participant, Partially Qualified Participant, and not qualified.
Volume is analyzed in two ways: by the number of patients or the dollar amount of Medicare payments.
For the 2023 participation year, a provider is a Qualified Participant (QP) if:
- The REACH ACO generates at least 50% of Medicare Part B Payments for 2023
- Or at least 35% of distinct Medicare Part B beneficiaries are seen through the REACH ACO
Qualified Participants have no MIPS requirements and no option for voluntary participation.
A provider is a Partial Qualified Participant in 2023 if:
- At least 40% of Medicare Part B Payments are generated for 2023 through the REACH ACO
- Or at least 25% of distinct Medicare Part B beneficiaries are seen through the REACH ACO
A Partial QP must decide whether to participate in MIPS or not.
The third pathway is ACO participants who do not meet either the Qualified Participant or Partial Qualified Participant threshold.
These providers will have a MIPS liability unless they qualify for an exception, like the new provider exception or the low volume exclusion.
To sum it up, the three pathways to MIPS are:
- Providers in your practice but not participating in the ACO have a MIPS liability.
- Providers in your practice participating in the ACO but falling below both Partial QP volume benchmarks have a MIPS liability.
- The two pathways above have no choice. Unless they have another exclusion, CMS will score them on MIPS, and they’ll suffer the total 9% negative adjustment if they do not make a MIPS submission.
- And Partial QPs get to decide. Before the end of the performance year, they must choose to participate in MIPS or not. If they do not, there are no penalties. If they decide to participate, they are fully subject to the MIPS adjustment based on their total MIPS score.
Question Two: Addressing MIPS in a REACH ACO
Katherine asks: “For our practice in a REACH ACO, how do you recommend we address MIPS?”
The most straightforward strategy is to skip MIPS and accept the full 9% negative adjustment for all providers with a MIPS liability. This strategy would also assume that any Partial QPs will elect not to participate in MIPS.
To help you decide, do a simple cost/benefit analysis comparing the monetary cost and the effort necessary to submit compared to the total potential loss in negative adjustments if you don’t submit.
The next more aggressive strategy would be to prepare and submit a group submission for your practice covering all providers who either must or could choose to submit.
In this case, the dynamics of a group submission would be the same as for any group submission. Data for all providers, whether in the REACH ACO or not, would be submitted but only benefit those with a MIPS liability.
The most aggressive strategy would be to be strategic and selective.
You’d want to engage a registry with capabilities like ours and submit claims throughout the year to identify your providers and their measure eligibility. You would also start monitoring the QPP Participation Status tool at each snapshot period to identify your providers’ submission eligibility status.
In the latter half of the year, you would choose the most promising measures to meet the needs of your presumed MIPS-eligible providers and test the performance rates. This data will help you decide whether your Partial QPs should participate in MIPS.
Let’s talk about submission dynamics for MIPS in a REACH ACO:
There are four MIPS performance categories to address.
You don’t make any submissions for Cost. CMS will measure your MIPS participating providers on all Cost measures that apply to their submission type and for which they meet or exceed case minimums.
You can limit your Cost measure liability using one or more MVP submissions. MVP submissions limit your Cost measure liability to just those specific Cost measures attached to the particular MVP.
Any of your REACH participating providers who have or choose to have a MIPS liability will get full credit for the Improvement Activities category by virtue of the APM/ACO participation.
Your providers not in the REACH ACO will need to address Improvement Activities. For a group MIPS submission, your REACH participating providers might carry the Improvement Activities requirement for the whole group by virtue of APM participation credit.
A submission for the whole group would cover this for all MIPS-liable providers. And it is probably the cost-effective submission option.
A group submission of any six MIPS measures or four choices from an MVP would be satisfactory.
If you’d like to be more strategic, there will be individuals whose MIPS Quality score, alone in an individual submission, would be higher than the group’s score. If you were to make supplemental individual submissions, the affected providers would receive the highest Quality score available to them.
In summary, there are two strategic choices when addressing MIPS in a REACH ACO:
Will your Partial QPs participate in MIPS or not?
- You’d like a reasonable estimate of each expected MIPS score before you choose.
- By the fourth quarter of each year, near the end of which Partial QPs must make their MIPS participation decision, you should have pretty good estimates of scoring on Quality, Improvement Activities, and Promoting Interoperability.
- You can’t be sure about Cost, which is not submitted but calculated by Medicare.
- Last year’s Cost scoring is your best guide for what to expect this year.
- You should factor in any aggressive efforts you have implemented to improve your Cost performance.
If you expect your score to give you a positive adjustment, Partial QPs should participate. If you expect your score to provide a negative adjustment, Partial QPs should not.
For Partial QPs and those providers who have no choice, will you make select individual submissions?
- You may find value in select individual submissions because, in the final MIPS analysis, Medicare will grant the highest earned score to participants with multiple submissions attributed to them.
Some of your individual providers would get a better score individually than the group receives from the group submission. If the difference is significant enough and the cost of submission is low enough, it would serve the practice better to make targeted individual submissions.
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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.