In this episode of Ask Dr. Mingle, Dr. Dan Mingle answers listener questions about transitioning from MIPS CQMs to eCQMs for the APM Performance Pathway (APP), the Qualified Participant Conversion Factor for Alternative Payment Model (APM) participants, and MIPS submissions “just in case” in an MSSP ACO.

Use the links below to jump to a specific question and answer, or click play on the video to listen now.

• Transition from MIPS CQMs to eCQMs
• Qualified Participant Conversion Factor
• MIPS Submissions for MSSP Participants “Just in Case”

Question One: Transition from MIPS CQMs to eCQMs

Glenn asks: “I’m worried. Medicare has this ‘Digital Strategy’ and they’ve proposed to discontinue MIPS CQMs for the APM Performance Pathway (APP) in the future. It seems like the writing is on the wall and one of these days eCQMs will be our only choice. How are we going to make that transition? It seems insurmountable.”

The primary goal with any quality reporting program is to report your clinical quality performance accurately and efficiently. It has to meet the standard that we attest to every year: “Complete and accurate to the best of our ability.” It can be done with MIPS CQMs, eCQMs, Medicare CQMs, or anything else Medicare might come up with.

Medicare CQMs will be temporary. Medicare wants us to have all-patient all-payer reporting and that is not Medicare CQMs.

When it comes to MIPS CQMs and eCQMs, Medicare wants to get us to all-electronic reporting. That can be either MIPS CQMs or eCQMs. eCQMs can’t be anything else but all-electronic. So, most people consider eCQMs as synonymous with digital reporting. But you can do MIPS CQMs as all-electronic.

At Mingle Health, we’ve done a lot of all-electronic MIPS CQM reporting. In the first few years of MIPS, when there was still a bonus for all-electronic reporting, we earned the incentive for many of our clients using MIPS CQM reporting.

Let’s compare and contrast the options.

First, the specifications, in format, are different.

• eCQM specifications are written in technical language and refer to standard code sets, specific standard codes, and value sets.
• MIPS CQM specifications are written in standard language. It refers to only the two code sets that are reliably standardized in everyday use. Those are:
  • Current Procedural Terminology: American Medical Association’s CPT codes
  • International Classification of Diseases, ICD10 codes by the World Health Organization and the US Center for Disease Control

But the two sets of specifications mean pretty much the same thing: what eCQM specs say using technical terminology is said by MIPS CQM specs using plain English.

Furthermore:

• Any data that can be used to create an eCQM can be used to create a MIPS CQM, including:
  • QRDA.
  • HL7 CDA of a wide variety.
  • And many people don’t realize that eCQMs don’t require QRDA. They can use direct data extracts from CEHRT.
• But the he reverse is not true. Many data sources that can be used to create a MIPS CQM cannot be used to create an eCQM.
• eCQM destined data has to be collected by and recovered from Certified EHR Technology (CEHRT).
• MIPS CQM destined data can be electronically sourced but can also be:
  • Manually abstracted from a paper source or an EHR.
  • Derived from a secondary electronic source like an immunization log, tumor registry, or other specific disease or treatment registry.

Each code set exists as a standard and calls for standard usage. But they are redundant and overlapping and no single standard is agreed upon or required.

The National Library of Medicine lists and tracks 105 standard code sets and offers translational tools for many.

Second, there are not as many measures available in eCQMs as in MIPS CQMs.

Medicare does not create or maintain measures. Medicare sets the standards, judges the various measure candidates submitted by experts and expert organizations, and maintains a library of applicable/acceptable measures.

It must be easier to author and maintain MIPS CQM specifications than eCQM specifications judging from the current availability and the annual turnover of measures. That’s another reason why we should not be overly quick to eliminate MIPS CQMs for eCQMs.

Now let’s talk about the process of switching from MIPS CQMs to eCQMs. What should you do? What should you not do?

I recommend that your analysis and reporting process, every year, includes a layer of data validation.

You should take a modest sized sample of data from the analysis and manually compare it to the chart to be sure performance analysis is accurate.

You should take ten to twenty examples of Performance Met and be sure that you can find the chart entries that define Met Performance.

You should take ten to twenty examples of Performance Not Met and look for data that should have made it Met.

In those cases where your chart audit, or data validation, shows that the analysis was not accurate you will then launch two actions:

• You will look for the error in the data flow. Determine and correct the reason the right data was not reflected in your analysis.
• You will correct the report to reflect a higher earned score.

This pertains to eCQMs and MIPS CQMs equally. The only thing that differs is your options for correcting this year’s score.

If you discover a discrepancy, I’d suggest you expand your data validation to include all patients who don’t meet performance.

If you are doing MIPS CQMs, you can take the results of that analysis to update your data. Usually, this is in an excel spreadsheet. And we can use that to correct your MIPS CQM submission.

If you are doing eCQMs, you put corrective entries in the EHR. I’d empower support staff to take data found in one format and reenter it in the format in which it can be found by your reporting process. Then submit new data.

The other error I see commonly made in eCQM project is to invest too much in infrastructure.

It comes down to two expensive upgrades:

• Enterprise Master Patient Index (EMPI)
• Central Data Repository

Both are great tools with a lot of potential value if you are actively sharing and using EHR data at the point and time of care every day. But it is serious overkill, that is, overspending, if the sole purpose is quality reporting.

A good EMPI and a good data repository with solid processes around them can get you to six sigma error rates.

But the limit of Medicare’s comparison between practices is nearer the three sigma level. To compare practices and decide MIPS incentives or collection of shared savings, Medicare goes out to two decimal places beyond a decile rank. We can get that from data that is typically native to HIT systems.

The monumental expense involved in implementing and using an EMPI and a Central Data Repository involves purchasing the necessary hardware, licensing the necessary software, and putting a team in place the work the errors every day. Save that expense and effort for when you will use it to increase the value of your care to your patients. You don’t need it to measure the value of your care for Medicare.

Question Two: Qualifying APM Conversion Factor

Lisa asks: “In the QP (Qualified Participant) look up tool on qpp.cms.gov, I read: ‘2024: The clinician will receive a Physician Fee Schedule update on services furnished in the Payment Year based on the 0.75 percent qualifying APM conversion factor. Voluntary reporting won’t affect this.’ What exactly does this mean? Is there any benefit to reporting?”

It’s a confusing statement on more than one level.

• What does it mean, “Voluntary reporting won’t affect this”?
• Does “2024” refer to the Performance Year or the Payment Year?
• It is an incomplete description of the incentive offered for QPs.

To orient everyone, this refers to Advanced Alternative Payment Models (APMs).

There is a threshold measurement of your patients who are attributed to you in APM. If you exceed that threshold, you are considered a Qualified Participant (QP) in that APM. Medicare offers an incentive for providers who become QPs. This statement in your question refers to that incentive for QP status.

Let’s take a closer look at the statement below.

First: “Voluntary reporting won’t affect this.”

It basically means that the incentive for being a QP does not depend in any way on reporting. You don’t need to make a MIPS submission to earn it. You don’t need an APP quality submission to earn it. If your quality score is low, you will still be awarded the incentive.

Second: The statement is also confusing in that it is unclear whether it is referring to Performance or Payment Year.

In the context, I know that this statement refers to the 2024 Performance Year.

If you become a QP for the 2024 Performance Year, you will receive higher reimbursement on your Medicare claims in the 2026 Payment Year.

Medicare payments are made based on the Physician Fee Schedule that Medicare updates every year.

• The Physician Fee Schedule is based on a series of Resource Value Units (RVUs).
• After adding up the RVUs for your billed CPT code, the RVU value is multiplied by a conversion factor to come up with the allowable amount for reimbursement.
• Every year that conversion factor increases by 0.25%.
• But for QPs, their Conversion Factor will go up by 0.75%, giving each QP better payment than everyone else gets for equivalent service.
• The 2024 Performance Year, for the 2026 Payment Year, is the first time that Qualified Participants will get this type of incentive payment.
• This favorable conversion factor is expected to continue indefinitely.

And finally, the statement oversimplifies the QP incentive.

The program started with an annual 5% lump sum payment for being a QP.

• You became a QP in the Performance Year. The first Performance Year was 2017.
• 2018, the year after the Performance Year, was the “Base Year”.
• 2019, two years after the Performance Year, was the Payment Year. Each QP was paid 5% of Base Year eligible Medicare Allowable charges in a lump sum.

The 5% lump sum incentive ended after the 2022 Performance Year. Meaning the last 5% lump sum incentive is/was paid in 2024.

Medicare added a 3.5% lump sum payment for APM Participants who became QPs in 2023. That 3.5% lump sum will be paid to 2023 QPs in 2025. The incentive will be based on 2024 billings.

The 2024 Performance Year became more interesting in March 2024, when a “Minibus Appropriations Package” passed by congress and signed into law on March 9, added a 1.88% lump sum payment in 2026 for APM participants who became QPs for 2024.

This 1.88% additional lump sum incentive is in addition to the favorable conversion factor already scheduled to be paid in 2026 for those same participants who became or will become Qualified Participants in 2024.

It seems simple, but there is some ambiguous and even contradictory guidance out there and it does not all seem to be documented as carefully in the Electronic Code of Federal Regulations as is customary.

In review:

I’m answering this question in 2024.

APM participants who became Qualified Participants, (QPs) in 2022 have received or will be receiving the last 5% lump sum incentive calculated on their 2023 allowable Medicare charges.

This year, 2024, is the base year for APM participants who became QPs in 2023. They will get a lump sum incentive payment in 2025 based on this 2024 year’s Medicare Allowable Charges.

APM participants in this 2024 Performance Year will get a 1.88% lump sum incentive in 2026 based on Medicare Allowable charges in 2025.

And they will also get higher payments for all of their 2026 patient services.

After the 2024 Performance Year, 2026 Payment Year, we expect to see no more lump sum incentive payments. We are expecting to continually see a higher payment for Medicare Payment Year services based on a higher QP specific conversion factor.

Question Three: MIPS Submissions in MSSP

Kristin asks: “Many of my clients are participants in an Advanced Alternative Payment Model (APM), like the Medicare Shared Savings Program (MSSP). Many of them continue to make MIPS submissions ‘just in case’. Is there value in that?”

There is potential value, and it relates to Qualified Participant (QP) status.

It’s not enough to participate in an APM, you have to hit a threshold number of Medicare beneficiaries or a percentage of Medicare billings that get attributed to the provider through the APM to be a Qualified Participant.

If a provider, by hitting those thresholds, becomes a QP, a MIPS submission is entirely unnecessary.

But, providers in an Advanced APM that do not achieve QP status may have a MIPS liability and might get a maximally negative MIPS adjustment if they have not made a MIPS submission.

The details differ for different APMs.

All APMs are required to be subject to some kind of quality analysis. In the MSSP, the APP (APM Performance Pathway) is required to collect any shared savings that are generated by the ACO. The APP serves as a MIPS submission for MSSP participants who need one. That is not necessarily the case with the quality reporting required in other APMs.

A MIPS submission for your providers who are in APMs can be a wise precaution:

• If they do not make QP status, they might need a MIPS submission to prevent a deep MIPS penalty.
• We have encountered some APMs that fail to submit their reports. If your provider is counting on the APP submission to count as the MIPS quality submission, they are completely out of luck if the ACO does not submit.
• These providers might generate better scores on their own than the ACO generates. If they are subject to MIPS, their own submission might give them a better MIPS adjustment than the ACO score.

Send us your value-based care questions!

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

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.