Dr. Mingle on the Healthcare Efficiency Through Flexibility Act and Self-Submission of Medicare CQMs for ACOs
In this episode, Dr. Dan Mingle answers listener questions on if ACOs can self-submit Medicare CQMs without a registry, shares his thoughts on the Healthcare Efficiency Through Flexibility Act, and explains the process of vendor validation for compliance with Promoting Interoperability requirements.
Click play on the video below to listen to this episode now, or scroll down for the written summary.
Question One: Submitting Medicare CQMs as an ACO
Sean asks: “We are a single-TIN MSSP ACO considering submitting Medicare CQM quality metric results. I’m unsure whether we are allowed to construct the JSON file ourselves that we’ll submit on the QPP website. Obviously, we could use a registry to do this. But we already have all our data at the ready, our list of ACO beneficiaries, and the ability to craft a simple JSON file. Is there any obstacle to me authoring the JSON file for my ACO quality submission myself?”
Yes, you can submit it yourself, but there is a barrier you will have to overcome.
Web Interface reporting (the process that just sunset and was replaced by the APM Performance Pathway) was intended and designed to be self-serve. But to submit Medicare CQMs, you must be a Medicare-Qualified Registry. Your submission must include a valid Registry Identifier to be accepted.
It’s achievable. I built my first Qualified Registry when I was Director of Clinical Informatics in the community health system in which I was a member of the family practice residency faculty. Since then, I’ve been involved in the creation of eight additional registries, with Mingle Health being my latest and greatest.
The first step toward doing it yourself is to find and download Medicare’s Qualified Registry Self-Nomination Toolkit.
In searching for it to prepare this answer, it was a little difficult to find.
- I found it in the Resource Library on the Quality Payment Program website.
- From there, download the “2025 MIPS Guide to Using a QCDR or a Qualified Registry”
- In the guide, you will find a link that will take you the “2025_Self-Nomination_Resources_Toolkit”
- The toolkit is a Zip file containing four PDFs that describe the requirements and process for initial qualification and the requirements and process for annual maintenance of qualification.
Initial qualification is mostly a set of attestations that you have a certain set of skills, capabilities, and experience.
Annual requalification involves demonstrating accuracy in reporting, creating and following an annual audit plan, attending monthly mandatory meetings with CMS, and participating in random CMS audits as requested.
You probably need, at minimum, 3 FTEs buried in this process. One subject matter expert keeping up on the rules and proposed rules, the opportunities and threats. One technical resource to manage the electronic processes that collect, analyze, and submit the data, and an administrative asset to keep up with Medicare requirements and connect to your practices to keep the accurate usable data flowing.
I recognize that I am more than a little self-serving when I say: “leave it to the professionals.”
Don’t try this at home, folks.
I’m not sure I would still be a qualified registry if I were still working in a community health system.
No single requirement of the process is particularly difficult. But Medicare changes the rules frequently and sometimes with very little advance warning. There are a lot of details and obscure requirements creating an environment in which small errors are easy to make, and those are errors that can invalidate a submission, costing a healthcare organization millions of dollars in uncollected shared savings or negative MIPS adjustments.
Medicare publishes a list of qualified registries every year and I am seeing the number of registries diminish year over year. Attrition seems to be particularly large among the do-it-yourself organizations.
Some of our happiest clients are those who have done it themselves in the past.
We would be delighted to help if you would be so kind as to engage us. It is what we live for.
Question Two: Health Care Efficiency Through Flexibility Act
James asks: “I just stumbled across a proposed bill to delay the requirement for eCQMs for ACOs submitting the APP Plus measure set. Is this proposal a good thing?”
The bill you cite is the “Health Care Efficiency Through Flexibility Act” that has been drafted and recommended by the House Energy and Commerce and Ways and Means committees.
This short, direct, 794-word bill pertains to APP Plus reporting by MSSP ACOs. It proposes to direct CMS to postpone the sunset of MIPS CQMs and the requirement to use eCQMs until at least January 1, 2030. It includes some language to study the process and protect organizations from financial loss if they aren’t using eCQMs.
The bill is endorsed by:
- Vern Buchanan, Republican congressman from Florida
- Jimmy Panetta, Democrat congressman from California
- Dan Crenshaw, Republican congressman from Texas
It is also endorsed by several large healthcare organizations and The National Association of ACOs (NAACOS).
I think it is great, and I will be expressing my support and encouragement to the sponsors, and to my own congressional delegation.
If I would recommend any improvement on the bill, I would suggest that CMS never require eCQMs.
I believe that electronic reporting is good and desirable. Every organization should aspire to it.
But it should never be required.
To get to value-based care, there are two essential “Outcome Measures”: Quality of Care, and Cost of Care.
Nothing is more important to value-based care than to measure, compare, and improve quality and cost of healthcare. Against those goals everything else is of trivial importance, including whether reporting is done fully electronically, fully manually, or a combination thereof.
If electronic reporting is effective and efficient and saves cost for our health care system, it will be adopted by health care providers when and if the barriers have been addressed adequately. To mandate the change earlier than the industry is ready can only hurt health care systems, providers, and, ultimately, patients.
In fact, I think that:
- All-manual reporting is unsustainable, unscalable.
- All-electronic reporting is achievable and is sustainable and scalable into a complete system of monitoring and assuring health care quality.
- Not just with a handful of measures for MIPS or ACO compliance, but for 70,000 evidence-based requirements of 350 million United States residents.
- But the most accurate reporting will be electronic with manual oversight and augmentation.
Once this bill completes the circuit of the house and senate, who knows how it will be amended or what unsavory other actions it might be bundled with.
For now, I support the bill as written and hope you will as well.
Question Three: Vendor Validation for Promoting Interoperability
Carrin asks: “I have a question from a small practice MIPS participant who is using eClinicalWorks – would they need to hire a third-party vendor to validate their EMR for Promoting Interoperability? And do you know if there is an exemption available for small practices for the PI category?”
There is still a small practice exclusion from the Promoting Interoperability MIPS performance category. Practices with 15 or fewer providers have an automatic exception.
Confirm your small practice exception on the Quality Payment Program website. Enter your National Provider Identifier (NPI) into the “Check Your Participation Status” dialog box prominently displayed on the homepage.
As to vendor validation:
- EHRs validate themselves. To call themselves “Certified”, they must, through examination by a certifying vendor, meet the relevant certification standards set by the Office of the National Coordinator (ONC).
- Certification is modular. An EHR might provide the whole certified product, or you might be using elements of multiple products that, together, make up a fully functional wholly certified system.
- If the product you are using is home-grown, or critical parts of it are, then you can seek your own certification. It has to meet the certification standards through examination by an independent certification vendor.
Most of us use a product or a suite of products that are certified.
If that is your case, you simply need to create and download a certification ID from the HealthIT.gov website.
You can engage a third party to help you. But the process was designed by the ONC to be self-serve without too much time or hassle.
Go online to the Certified Health IT Product List (CHPL) at https://chpl.healthit.gov/#/resources/overview
Follow the instructions at “How do I create a CMS EHR Certification ID?”
You will search for your product and version number and, if certification is confirmed, push a button to add it to your certified products list to create your unique certification ID.
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.
Our PDF guide provides critical information for MSSP ACOs as they tackle new quality reporting requirements for the 2025 Performance Year.