APP Plus Scoring Explained, How Billing Professionals Can Protect Providers from MIPS Penalties, and more
In this episode of Ask Dr. Mingle, Dr. Dan Mingle answers great questions from listeners on APP Plus scoring, calculation of claims-based measures for MSSP ACOs, attribution challenges in an ACO serving the post-acute space, and how billing professionals can protect providers from MIPS penalties.
Click play on the video below to listen to this episode now, or scroll down for the written summary:
Question One: APP Plus Scoring
Gillian asks: “How does the scoring change for the APP Plus measure set when more measures are added each year?”
As you know, in the Final Rule for 2025, Medicare added the APP Plus measure set.
Starting in 2025, Medicare Shared Savings Program (MSSP) ACOs must submit the APP Plus measure set and meet or exceed the quality standard in order to collect shared savings or avoid maximum shared losses.
Other APM models can elect to use the original APM Performance Pathway (APP) measure set or the new APP Plus measure set if they wish. Neither set is available to traditional MIPS or MVP participants.
The measure set is scheduled to gradually increase to include all adult Universal Foundation measures.
Scoring for APP Plus depends on your circumstances.
ACOs in the first year of the first participation cycle remain pay-for-reporting. Making a successful submission of all measures with each meeting data completeness and minimum patient counts is all it takes to qualify to collect shared savings.
If you are submitting the APP Plus measure set using Medicare CQMs, you must hit the usual quality standard.
Each measure can earn between 0 and 10 quality achievement points based on decile ranking of the measure performance against peers.
The total score is calculated by adding the total possible points as the denominator and the total earned points as the numerator. You collect all of your shared savings if your aggregate score meets or exceeds the quality standard which is now the 40th percentile. It doesn’t matter how many measures apply. You will get one aggregate score represented by your total earned quality achievement points divided by your total possible points.
If you are submitting MIPS CQMs or eCQMs, Medicare is offering an alternative quality standard to incentivize participation in an all-patient, all-payer measurement of quality. The alternative standard looks at individual measure scores rather than the aggregate or composite.
For the alternative standard, the more measures there are, the more chances you have of achieving the alternative standard.
The alternative standard is:
- One outcome measure has to have a score hitting at least the 10th percentile.
- Any second measure must be at the 40th percentile.
You should also be aware that there is a new complex organization bonus for which one achievement point is added to each individual measure score that is submitted by an ACO as an eCQM. The bonus is not permitted to bring an earned score for any measure above a perfect 10 points. They are not explicit as to how this bonus interacts with the alternative quality standard, but I expect the standard will be applied after the bonus is calculated in.
Question Two: Calculation of Claims-based Measures for MSSP ACOs
Gillian asks: “Is the calculation for the two claims-based measures for MSSP the exact same as in ACO REACH?”
The answer is no.
You are referring, I think, to the administrative claims measures:
- Hospital-wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate which is MIPS measure number 479
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions which is MIPS measure number 484
We see these measures in at least three places:
- Included in every MVP
- Included in the APP and APP Plus measure sets
- Amongst the measures on which REACH ACOs are evaluated
They are precisely the same, using the same specification sheet when used in MIPS, MVPs, or in the APP or APP Plus measure sets.
But regarding REACH, Medicare deliberately describes the REACH specifications of these measures as based on but not identical to the MIPS-specified measures. Even the format of the specification documents is different. You can find the REACH specifications in Medicare’s REACH model “Quality Measurement Methodology Report”.
The measures clearly differ in eligibility criteria and may differ in adjustment methodologies and other details. A limitation of my analysis is that the formal or full specifications for the REACH measures are not readily available.
Question Three: Measure 484 Changes for ACOs
Zach asks: “In the 2023 results only 45% of ACOs got a value for measure 484 All-Cause Unplanned Readmission (HWR) Rate Multiple Chronic Conditions. It was fully populated in 2022. Any idea what happened in 2023?”
Gillian asks: “CMS is keeping the Clinician and Clinician Group Risk standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions for PY2024 but removing it for PY2025 and then bringing it back for PY2026? Do I have that right?”
I’ve grouped these questions together because I believe them to be related to the same issue.
There is a problem with measure 484:
- The specifications exclude patients that are attributed to a provider who achieves Qualified Participant status for the performance year.
- Now that that measure is being used in the APM Performance Pathway, advanced APMs are subject to exclusion of many, or possibly all, of their patients from the measure calculations.
Zach, I’m not satisfied that that phenomenon explains your observation. Digging back into the specifications over the years that I can still access shows that this exclusion has existed unchanged for performance years 2022, 2023, and 2024. In a year that an ACO moved from MIPS APM status to Advanced APM status, and most of its participating providers became QPs, you’d expect a dramatic drop in patients eligible for the measure.
I’m more confident, Gillian, that this is the reason why the measure is gone for 2025, then back in 2026.
Specifically, it is continually present in the APP measure set. Not gone then back.
CMS chose not to bring it forward into the APP Plus measure set while they decide if its specifications should be changed.
I think they should change it. The reason they give for having the exclusion is that QPs don’t participate in MIPS. But now that all ACOs are subject to this measure, QP patients should be included in the measurement. It is just as important for QPs to prevent the need for hospitalization as it is for all other clinicians.
Excluding patients attributed to QPs renders the measure less valid.
Question Four: Attribution Challenges for an ACO in Post-acute Care
Jason asks: “We spoke with an ACO that serves the post-acute space. Patients seen in Skilled Care, Place of Service code 31, are limited to a short stay and are excluded from attribution. Though the intent is to get them home after a short rehabilitation, many are discharged to long term care, Place of Service Code 32, which has no limitation on duration and is eligible for attribution. The ACO continues to provide care to these patients for the duration of their stay in long term care. This ACO finds that many of these patients, discharged from long term care to home after a few months do not establish with a community PCP and remain attributed to the long term care providers who don’t have a venue in which to continue serving them post discharge. Are there specific strategies or best practices you’d recommend to address this attribution challenge?”
I can see how those patients become a risk to your cost performance. Controlling that risk is the challenge.
I see two domains to address to control that risk:
- Discharge planning
- Solidifying the transfer in responsibility
One set of risks is to the daily care plan. On the transition to home there is dramatically less supervision, monitoring, and support of activities of daily living. Compliance levels will change in terms of exercise, diet, medication. Costly events become more likely, mostly related decompensation of fragile chronic conditions. But falls and other injuries also contribute to the risk of high-cost events.
Control this by upping your game in discharge planning. Mobilize the family and community care teams.
The other risk is to get lost to medical follow-up or simply confused or delayed in the transition. Prior studies have shown that people who have a primary care provider, know who it is, and have access to them, enjoy better care and lower cost of care.
Control these risks with careful planning for transitions. I suggest meeting with regional primary care providers to secure agreements to accept your patients on transfer to home and to outline expectations when the transfers happen.
You should consider, as part of the handoff, an annual wellness exam through the new primary care provider. It would nicely facilitate both the transition care and the transfer of attribution. An annual wellness exam is a great review of the patient’s comprehensive needs, a great introduction for a new provider, and the billed performance for this service takes precedence over most other triggers of attribution.
Consider facilitating the kickoff of the annual wellness exam within your own discharge process. Distribute or even administer a standard risk assessment tool leaving the final analysis and billing for the service to the new PCP.
Consider solidifying the transfer of attribution. Help the patient select the provider who will be accepting the patient as their new primary provider through Medicare.gov. In most cases, this prospective attribution takes precedence over all other methods.
Some reasonable combination of the approaches I have outlined is simply good health care, effectively transferring care, responsibility, and attribution to the new provider.
Question Five: Billing Professionals and MIPS Penalties
Adnan asks: “How do we, as billing professionals, help protect providers from MIPS penalties?”
I think that billing professionals are in a unique position to provide protection of their clients through guidance, information, and service in support of the Quality Payment Program (QPP), the Merit-Based Incentive Payment System (MIPS), and other value-based payment programs.
There are three things I’d suggest revenue-cycle organizations endeavor to build into the client relationship:
- Routinely alert client practices to the existence, the risks, and the benefits of value-based programs that may affect them.
- Keep client practices apprised of important due dates.
- Provide guidance and/or technical support for your client practices to access and submit their data to the vendors they have engaged to help them with their value-analytics.
The unique position of revenue-cycle organizations relates to three elements:
- Revenue-cycle organizations often have a closer relationship and deeper knowledge of insurers, their requirements, and their value-based programs than do the practices that they serve.
- Even if unvoiced, practices are looking to their revenue-cycle partners for help both to identify and reap the revenue benefits from such programs, and to avoid revenue losses.
- The foundation for measurement of value is built on visits and claims. Together visits and claims define the patient-doctor relationship, the range and volume of services provided within that relationship, and the range of diagnoses, injuries, and illnesses that drive individual patient needs. This is the gold-standard dataset that determines eligibility both of practices for specific programs and of patients for specific measures.
- Finally, there is typically a foundation of technology in the relation of revenue-cycle organizations with their clients. Revenue-cycle companies routinely interact with the practice management and billing data of their client practices. They sometimes have a role in the clinical EHR data of the practices they serve. They can be of invaluable support to their clients to help them access and deliver data to the vendors that help them analyze and submit quality-measures to CMS and other insurers.
Mingle Health has partnered with many revenue-cycle companies.
Too often, revenue-cycle companies reach out to us after one or more clients have already experienced a loss.
Earned or not, revenue-cycle companies are first in the path of blame assigned for those losses.
- To some, we are a favored vendor. Their client practices engage us directly on their recommendations.
- To others, the revenue-cycle company is a value-added reseller. They typically maintain the vendor-client relationship, buying Mingle services at wholesale prices that they resell to their clients. They add value by delivering standardized datasets to Mingle usable by Mingle to generate annual quality submissions.
- In both cases, Mingle can provide the revenue-cycle company with updates on the changing environment of program risks, opportunities, and deadlines.
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.
For many ACOs, the transition to all-patient, all-payer quality reporting is a significant challenge and often feels like an unnecessary burden imposed by CMS. We've created our latest PDF guide to help ACOs orient themselves to the challenge of all-patient, all-payer reporting while finding opportunities to thrive in the future.