This episode of Ask Dr. Mingle features an in-depth discussion of Promoting Interoperability requirements for ACOs with Dr. Dan Mingle and Brigid Whitney-Gallagher, Manager of Client Services at Mingle Health.

Click play below to listen to this episode, or scroll down for the summary:

Question One: Promoting Interoperability Explained

Brigid asks: “Before we jump into Promoting Interoperability requirements for ACOs, can you just do a quick refresher on the PI Category?”

Dr. Mingle: Let’s just say it’s all about the use of Certified EHR technology or CEHRT.

PI is one of four MIPS performance categories. A PI score, that is a Promoting Interoperability score, typically contributes 25% of the final MIPS score, except in cases of reweighting.

But practices and providers can be eligible for an exception for any performance category. Exception means that you get forgiveness for not reporting that category. In an exception, the weight that that category carries into the MIPS score gets redistributed to the remaining MIPS categories that the submitter is responsible for. So, PI can go to zero if the provider or practice has an exception for PI, or PI can be increased if one or two of the other categories have exceptions.

Now, there are four objectives captured in PI measures, and there’s an overlay of required infrastructure attestations, which is almost a fifth objective, if you will.

On the required infrastructure attestations to get a PI score every year, you must attest that:

• There are no actions taken to limit or restrict interoperability of CEHRT
• That you’ve made an annual review of the High Priority Practices SAFER Guide published by the ONC
• That there is availability for the ONC to directly review issues in your CEHRT
• And you’ve done an annual security risk analysis

So those are the baseline infrastructure attestations, and they’re constructed so the right answer is “yes” for each of those questions.

And then there’s four measure-based PI reporting objectives:

• First is e-Prescribing
• Second is Health Information Exchange
• Third, there’s Provider to Patient Exchange of Data
• And finally, there’s Exchange of Data with Public Health or Clinical Data Registry

And there’s a variety of ways in each of those options to meet the objectives, and there’s also a variety of exceptions to each of those.

Brigid says: “I also just want to call out, in previous years, practices have been able to attest no to some of those required infrastructure attestations. In 2024, could a practice still earn points if they attest no on any of those?”

Dr. Mingle: I think you’re referring to specifically the SAFER Guide question, and for the first year or two that SAFER Guide attestation was in this list, you were only required to be aware of them. Just saying yes or no was fine to meet that attestation. Beginning with the 2024 performance year, that answer must be yes.

Question Two: Promoting Interoperability Requirements for ACOs

Brigid asks: “I think we understand a little bit of the PI category. How does that apply for ACOs? What are the ACO requirements? Do they have any, and what do those look like?”

Dr. Mingle: I think it’s helpful to think of this topic in two sets of two.

First, it’s current state versus future state, because there’s a change in the works. But we’ll get to that in just a moment.

And second, it’s different if you’re a MIPS APM versus an advanced APM. The requirements are a little different.

To further explain the dynamics between MIPS APMs and advanced APMs:

• Prior to the 2025 performance year, if you’re a MIPS APM, meaning that you’re in an APM, but it’s not two-sided, you’ll be getting a MIPS score and potentially earning a MIPS adjustment of some level.
• And the MIPS Promoting Interoperability category applies fully to anyone in a MIPS APM.
• For all APMs, MIPS or otherwise, routine reweighting of the Cost category is in effect. And in that routine reweighting, PI was 30% of the MIPS score for MIPS APMs compared to 25%, which is usually applicable to a traditional MIPS participant.
• And there’s a contractual requirement that at least 50% of participants in MIPS APMs are using CEHRT, and at least 75% of participants in an advanced APM must be using CEHRT.
• Now, if you’ve got a PI obligation in an APM, you can meet that as an individual TIN-NPI. Or you can submit as a group, that is all the NPI’s, in one TIN submit together, or you can submit PI as an APM. And that’s applicable to the 2024 performance year and beyond.

Brigid asks: “Dan, let me ask you, you stated there’s a contractual requirement that for MIPS APMs, 50% of participants use CEHRT, and for advanced APMs, it’s 75% of participants. Does that mean 75% or 50% of the NPI’s that are part of the APM, or is that another designation?”

Dr. Mingle: You’re absolutely right. It’s 50% or 75% of the NPI’s participating in the APM are using CEHRT.

Question Three: Future of Promoting Interoperability Requirements for ACOs

Brigid asks: “What does PI look like for ACOs in the future?”

Dr. Mingle: There’s a new rule that was introduced in the 2024 Final Rule, which changes the Promoting Interoperability requirements for ACOs as of the 2025 performance year.

Starting with the 2025 performance year, everyone in an APM, whether a MIPS APM or advanced APM, needs to use Certified Electronic Health Record Technology, that is CEHRT.

And everyone, whether a MIPS or advanced APM needs to make a MIPS Promoting Interoperability submission.

Both of those share the MIPS exceptions to PI, so the usual exceptions apply to both those using CEHRT for an APM and submitting PI from within that APM.

These exceptions apply at the individual or group level, except for the small practice designation, which if all the practices in an APM entity are small practices, the APM entity gets that small practice designation. But that’s the only exception that applies to the APM level.

And APMs are not allowed to apply for exceptions, but the individuals and the groups participating in the in the APM can apply for exceptions and be individually excepted, or excepted at the group level.

Brigid asks: “So in 2025, when we’re reporting for 2025 data, every provider, every NPI, will need to use CEHRT and need to submit PI unless they have some other exemption. Is that right?”

Dr. Mingle: That’s correct.

Medicare will, as part of their evaluation of the annual scoring and performance, look for a matchup between eligible participants in an APM matchup an applicable PI submission. That I think is likely to be their primary means of checking for compliance with the 100% use requirement.

Although they also have the option, because the contract exists, to audit the participating providers to make sure everyone’s using CEHRT.

Question Four: Promoting Interoperability Exclusions

Brigid asks: “For 2025, everyone has to use CEHRT and report PI unless there are some exclusions. So let’s talk about those exclusions. What are they? How do they work? How would a practice or provider or APM get them?”

Dr. Mingle: This is the same across all PI in the QPP, whether it’s MIPS or APMs starting in 2025.

Clinical social workers are still, for the last year or two, the only credential that gets automatically reweighted. Clinical social workers don’t have a PI obligation.

Providers or practices based in ambulatory surgical centers don’t have a PI obligation.

Hospital based providers or practices don’t have a PI obligation.

And small practices, that is practices with 15 or fewer clinicians in the practice TIN, the tax ID number, have no PI obligation.

You can check the QPP website to see if you have been granted any of these exceptions.

There’s also an annual application available for exceptions.

Medicare has four categories in which they grant exceptions for Promoting Interoperability, typically. You can apply for an exception if:

• The EHR technology that you’ve been using has been recently decertified.
• You can’t use CEHRT because your practice site has insufficient internet connectivity to make it usable.
• You lack control over the availability of CEHRT.
  • This is typically the case with a facility-based provider. And there’s a lot of facility-based providers that don’t fit those categories I mentioned in the automatic exceptions above.
• Then if there’s extreme and uncontrollable circumstances, like fires, floods, or significant illness or death in key members of the practice. There are many uncontrollable circumstances that can qualify for an exception annually.

One possible area for confusion I’ve found as I’ve been reading through the available data on special statuses available to APM entities: there’s a note that says small practice is the only status available to APM entities.

I think there’s a little room for confusion of what that means, so both groups, MIPS and APM participants may have some confusion. And even at the basic level, the help desk level at CMS, you may find some confusion.

Remember, an APM entity is not permitted to apply for exceptions. None of those application-based exceptions apply. This only leaves us with the small practice exception.

I think you should watch that carefully. And if you get a misinterpretation in your scoring, be prepared to contest that when the scores are out.

Brigid asks: “So let me just make sure I understand. For 2024, at the APM level, the only special status that could apply is this small practice status?”

Dr. Mingle: Correct. That’s at the APM level. Anything else can apply to individual practices or providers in the APM or even all of them, but in those cases, it’s evaluated at the practice or provider level. It’s not evaluated at the APM level.

Brigid asks: “So if I’m an ACO and I have five TINs, let’s say, that participate with me, and all of them have a status of being hospital-based, they wouldn’t have to report PI. So, there wouldn’t be an expectation of PI at the APM level as well, right?

Dr. Mingle: That is correct.

Question Five: How PI Requirements will Impact ACOs

Brigid asks: “Let’s talk a little bit about what this is going to look like in 2025. We know that in the 2024 Final Rule, CMS laid some groundwork for what they expect to be required for ACOs around PI reporting in 2025. What are you seeing with the 2025 requirements, and how do you think this will impact ACO practices?”

Dr. Mingle: The new rules were adopted with the 2024 Final Rule to go into effect for the 2025 performance year and beyond.

The first change is to the Promoting Interoperability requirements for ACOs is that everyone in each APM, that’s MIPS APMs and advanced APMs, needs to use CEHRT. There’s 100% requirement now. It’s gone up from 50% in MIPS APMs, and it’s gone up from 75% in advanced APMs.

Also, all of those providers need to submit for the MIPS PI category, and I expect Medicare is probably going to use that in part to assure compliance with the 100% requirement.

The usual exceptions apply to both of those issues. There are some exceptions that you don’t have to have 100% of users using CEHRT, and not 100% of users need to submit. The same exceptions that have always applied at the individual or group level to making a PI submission will apply to, collectively, each of those participants in the APM.

Brigid asks: “So, if there’s exceptions to be applied – any of those exception categories that are acceptable for PI – those applications need to be made from an individual or a TIN group level. So, in 2025, whether you are a MIPS APM or an advanced APM, whether you are a MIPS eligible or a QP or a partial QP, everyone has to use CEHRT unless they’re otherwise exempted, and everyone has to report PI unless they’re otherwise exempted.”

Dr. Mingle: You nailed it. That’s exactly correct.

Question Six: Why Would an ACO Choose to Report PI?

Brigid asks: “If TINs and NPIs can report the PI category on their own, why would the APM want to report it for them or be concerned about how practices or providers are reporting PI?”

Dr. Mingle: I think the APM is going to have a very big stake in this.

Medicare is not explicit about what will happen for noncompliance with this requirement, but I think that implicit in all contracts for MIPS or advanced APMs is what happens when you break that contract.

I think you can expect, at the very least, to get a stern warning and the requirement for a remediation plan.

And at worst, by being noncompliant with your contract, they may withhold any shared savings you may have earned.

Question Seven: Considerations for Promoting Interoperability at Different Levels

Brigid asks: “What should folks consider when they’re deciding whether to report PI at the provider level, the TIN level, or at the APM level?”

Dr. Mingle: Again, I think failure to have a valid submission applicable to each of the participants can affect your ability to collect on your shared savings. There’s a big role there to play.

I think for APMs, making a submission is a great idea just to take control of it and make sure you don’t have individual providers or participants neglecting this and affecting the whole group.

It has yet to be shown how Medicare handles it, but there’s an advantage when you move from an individual submission to a group submission.

Some of the measures that are attestation-based or that require just one numerator instance to pass – the whole group takes that. If you have only one who’s made that connection between patient and EHR, one that’s complying with the referral-based interoperability, that can apply to a larger group. I think there’s an advantage that you gained for the whole APM.

Now, there is some downside for the individuals, practices and groups. In cases where people are doing a great job and would get a higher score alone or as a group, they may get a lower score as an APM.

But there’s no reason you can’t do both.

We have a lot of people submitting quality submissions that do an individual submission for when the group is not getting as good of a score as they would be getting alone. Rather than accepting the group score, they make an individual submission to get a better MIPS adjustment. And that can happen here in the APM PI level as well.

Now, for your advanced APMs, there’s no other advantage of getting a PI score. It doesn’t go into any kind of adjustment if you’re a Qualified Participant. But if you’re a partial QP electing to participate in MIPS or a MIPS APM, it can make a difference in your adjustment if you accept the APM level score or make your own individual group submission.

Brigid says: “So, there are really two things to consider: It sounds like everyone should be concerned about satisfying the shared savings requirements.”

Dr. Mingle: Correct.

Brigid says: “And your non-QPs, meaning your MIPS APM folks or MIPS eligible providers, might see a negative adjustment if they don’t successfully earn those points in the PI category.”

Dr. Mingle: Correct.

And of course, remember that the danger is always there for a negative adjustment. So, putting your own better PI submission in might earn you a smaller negative adjustment or perhaps move you into the positive range.

You have to think about the whole range as you’re thinking about that potential for the year.

Brigid says: “As you mentioned, I know a lot of providers might choose to make an individual submission in the Quality, PI, and IA categories because their own score would be better than that of the group. It sounds like that might be a good strategy for providers or TINs to think about if they think their own score would be more successful than the score that would be achieved at the MIPS APM level.”

Dr. Mingle: I think you’ve nailed it, Brigid.

Question Eight: How Mingle Health can Help Your ACO with Promoting Interoperability

Dr. Mingle asks: “This all gives me a question I have for you, Brigid. You are prominent in our group of consultants helping our clients navigate the Quality Payment Program. How are you finding yourself and your group assisting our clients in this Promoting Interoperability realm with ACOs?”

Brigid: As I think we might have explored a little bit, PI is a category where there are lots of nuances and exceptions based on specific details.

Everything you and I have talked about today is from information that’s available through the QPP website, which is qpp.cms.gov.

They have an extensive library of documentation and information. The helpful part of that is that it’s all the information any circumstance could need regarding reporting PI in an ACO.

Mingle Health and our consultants shine our understanding of that information, and we can discuss how it applies to your situation.

As we mentioned, there are exclusions and exceptions and caveats. So, when you’re meeting with a consultant, one of the first things we do is understand what’s happening at your practice or at your ACO.

Then we’re able to explain how all of this, all of these regulations and requirements, apply in your circumstance, and we can work with you to get the best possible score.