In this episode, Dr. Dan Mingle answers listener questions about 2025 CEHRT requirements for MSSP ACOs and the impact of failure in APP Plus reporting for ACOs.

Click play on the video below to listen to this episode now, or scroll down for the written summary.

Question One: 2025 CEHRT Requirements for ACOs

David comments: “The big implication for us, in the Quality Payment Program rules for 2025, is the requirement that 100% of our ACO participants need to be on Certified Electronic Health Record Technology, (CEHRT).”

You are right, David, that has big implications for all ACOs.

As a reminder for all of you:

• Before the 2025 reporting year, ACOs that were Advanced APMs had a contractual requirement that 75% of their participants were using CEHRT.
• ACOs that were MIPS APMs had a 50% use requirement.
• Starting in 2025, both groups are contractually required to have 100% CEHRT utilization.
  • And all providers are required to submit a Promoting Interoperability MIPS performance category submission.

No question, this is hard and may force some practices out of your ACO.

There are some other factors remediating that new ruling that fall under the categories of good news and bad news.

First: good news. The exceptions that have always existed for the CEHRT-use-as-evidenced-by-Promoting Interoperability equally apply now to the 2025 CEHRT requirements.

So, despite the 100% utilization requirement, all of the exceptions, still in force, apply equally to ACO CEHRT use requirements as they do for MIPS CEHRT use requirements.

Both automatic exceptions and exceptions granted upon hardship application apply. There are exceptions for things like:

• Small practices (15 or fewer providers)
• Non-patient-facing practices/providers
• Facility-based providers
  • Hospital based and ambulatory surgical center-based providers
  • And others, by application

Second: bad news.

The Final Rule for 2025 queues the sunset of MIPS CQMs as an option for APP or APP Plus reporting in the 2027 performance year.

If this is not modified before then, you will need to make either an eCQM submission or a Medicare CQM submission.

With Medicare CQM submissions, the standard CEHRT exclusions will still apply.

But eCQM utilization will effectively end the applicability of CEHRT exclusions. You have to have CEHRT in order to make an eCQM submission. So, your practices that qualify for one of the CEHRT exclusion criteria will have to have CEHRT in order to contribute data to your APP or APP Plus quality reports.

Third: one last piece of good news.

You can use the Data Completeness requirement to modify the 2025 CEHRT requirements.

The Data completeness requirement remains at 75% for performance years 2025 and 2026. The requirement is as yet undetermined for the years after 2026.

Whatever the Data Completeness requirement is, you can “spend it” on practices without CEHRT. With that limitation in mind, you can still have practices without CEHRT in your ACO, but only to the extent that you can still generate electronic data analysis applicable to enough of your denominator patients to be at or above the data completeness requirement.

Question Two: Implications of Failed APP Plus Submission

Jason asks: “If an ACO fails APP Plus reporting in 2025 how would that impact them if they don’t have any shared savings to lose? Does it make a difference if the contract is two-sided?”

There is likely to be an effect in either case. Though the range and scope of effects differs for one-sided vs two-sided contracts.

If it’s a two-sided contract, the ACO is contracted to share in savings and losses. This is what is considered an Advanced APM:

• If there are neither savings nor losses for the year, their participating NPIs who have Qualified Participant (QP) status will not suffer from a low or absent quality score.
• If there are savings, the APP Plus score must hit, at least, the quality standard to collect all of the shared savings due.
  • But even a low score can qualify for partial collection of shared savings.
• If there is a loss, without a quality score, their share of losses would be at the maximum. A score at or above the quality threshold reduces the loss.
• There are often MIPS liabilities even in Advanced APMs and the lack of an effective APP Plus submission could be important. I’ll explain that shortly.

If it’s a one-sided contract, the ACO is contracted to share in savings, but not losses. Or there could be, in the agreement, what Medicare calls a “nominal share of loss” which is not enough to qualify for Advanced APM status. These ACOs are considered MIPS APMs.

All of the participants in an ACO that is a MIPS APM are still subject to MIPS scoring and adjustments.

• If there are no savings for the year, the APP Plus score is irrelevant to the collection of shared savings. If you know you are not going to score well, there will be no revenue boost from shared savings to pay for the reporting effort.

There is, though, a MIPS implication that needs to be considered.

There is always a MIPS implication in ACO contracts that are considered MIPS APM contracts.

There are usually MIPS implications in ACO contracts that are considered Advanced APM contracts.

The MIPS implication tracks to QP status. QP status depends on the percentage of patients seen or the percentage of Medicare revenue generated through patients that are ACO-attributed.

All participants in ACOs of the MIPS APM type have a MIPS liability. Non-QP status participants in ACOs of the Advanced APM type have a MIPS liability.

Let me just mention here the Partial Qualified Participant status. Partial QP is applicable to participants in ACOs of the Advanced APM type. Those choose whether they will be subject to MIPS or not. What I have to say about MIPS liabilities apply equally to Partial QPs who choose to be subject to MIPS.

The APP Plus submission has three implications for all ACOs, both MIPS APM and Advanced APM style ACOs.

• It determines qualification to collect any shared savings generated, and
• Can protect against full liability for shared losses, and
• Here’s the important part: it serves as a MIPS Quality Score for MIPS-liable participants in the ACO

MIPS-liable participants who don’t have a MIPS score will suffer the full 9% negative adjustment on all Medicare part B payments.

9% is a big loss.

Even a low Quality score when considered in combination with the ACO-relevant dynamics of the other performance categories can eliminate or at least significantly reduce potential negative MIPS adjustments.

Even a bad APP Plus score can be useful to your MIPS-liable participants.

You should be considering, for your MIPS-liable participants, or they should be considering for themselves, an alternative MIPS Quality submission.

Those MIPS-liable participants will be assigned, relative to the calculation of their MIPS adjustment, the best Quality score submitted on their behalf: the APP Plus score, a group MIPS submission, or an individual MIPS submission.

The bottom line is that you have to think about MIPS in your ACO, whether it is an Advanced APM or a MIPS APM:

• You might conclude it’s the responsibility of each practice to think about whether or not they would benefit from a Group MIPS submission.
• And it’s the responsibility of each individual provider, or their practice, to decide whether or not they would benefit from an individual MIPS submission.

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.

Want to learn more about quality reporting for ACOs in 2025?

Our PDF guide provides critical information for MSSP ACOs as they tackle new quality reporting requirements for the 2025 Performance Year.

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