In this episode, Dr. Dan Mingle answers important questions about MIPS requirements and liabilities within Accountable Care Organizations. Dr. Mingle explains Quality category requirements for MIPS-eligible providers in first-year ACOs, how MIPS scoring applies in Advanced APMs, and the impact of different ACO risk models on provider reimbursement.

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

Question One: MIPS Requirements for Eligible Providers in First Year ACOs

Janice asks: “In the first year of our ACO, APP scoring is pay for reporting. As long as we meet case minimums and data completeness criteria, we get full credit for Quality, no matter what our performance score is. Does that mean that our MIPS-eligible providers get full credit for Quality in calculating their MIPS adjustments?”

Great question, Janice.

The answer no.

You are referring to the quality standard for MSSP ACOs in the first year of their first contract period. They need, starting with 2025, to submit the APP Plus measure set, not the APP measure set. If their submissions meet data completeness requirements, they meet the quality standard for that performance year.

The APP Plus submission is also applicable to MIPS-eligible providers in the Tax ID Number (TIN) practices participating in the ACO.

Those MIPS-eligible providers in each TIN-practice are assigned the APP Plus score. It’s important to note that APP Plus pay-for-reporting credit is applicable only to the ACO quality standard, on which collection of the ACO share of shared savings depends.

For MIPS providers, it is pay-for-performance, not pay-for-reporting. The performance score matters.

For MIPS-eligible providers in your ACO-participating TIN-practice, they are also subject to the rules governing multiple submissions. To improve their MIPS adjustments, they are eligible to make multiple submissions. They will benefit from the highest submitted score.

If they expect that the APP plus score of the ACO is going to be low, it can be smart to make at least one alternate submission.

They can make individual submissions and/or participate in one or more group submissions.

They can make eCQM, MIPS CQM, QCDR, and/or Part B Claims submissions.

Question Two: MIPS Scoring in an Advanced APM

Janice goes on to ask: “I understand, now, that the APP Plus Quality score will apply to the MIPS-eligible providers in our ACO participating TIN-practices. If we are an advanced APM ACO, then MIPS scoring does not apply?”

Another great question, Janice.

The answer is no, there are still some MIPS requirements for Advanced APM ACOs. You are likely to need a MIPS Quality score for some of your providers even if you are an advanced APM.

The Medicare Shared Savings Program (MSSP), like any other APM, can be a MIPS APM or an Advanced APM.

In the case of the MIPS APM, none of the participating providers will be a Qualified Participant (QP).

Everyone will be subject to a MIPS score and a MIPS adjustment.

Participants in a MIPS APM are eligible to collect shared savings AND the MIPS adjustment will pile on top of that, adding to the gain, or diminishing the gain.

If you are an Advanced APM, none of your Qualified Participants will be subject to MIPS.

But there are likely to be providers in your ACO participating practices who are subject to MIPS.

It hinges on the QP designation. There is a threshold measurement, done by Medicare, that each provider has to meet in order be considered a QP.

It’s the percentage of the total unique Medicare patients you see that are ultimately attributed to the ACO. It’s calculated and tracked both by count of patients and dollars of allowable charges. Hit either of the year-specific thresholds and you are a QP.

In any individual practice in an Advanced APM, MSSP or otherwise, in any particular year.

• All providers may be QPs,
• Some providers may be QPs,
• No providers may be QPs,
• …no matter what your MSSP ACO contract looks like, MIPS APM or Advanced APM.

You always have to be alert for the MIPS-eligible, (or maybe we should express it as MIPS-liable) providers.

Your APP Plus submission might qualify you to collect all of your shared savings but still result in a negative MIPS Adjustment for your MIPS-liable providers.

Question Three: One-sided Risk vs. Two-sided Risk Impact on Provider Reimbursement

Robert asks: “In our basic MSSP ACO, with just one-sided risk, our participating providers can collect both shared savings and positive MIPS adjustment. Does that mean they can be better off than Qualified Participants (QPs) in MSSP ACOs that are two-sided risk, subject to shared savings and shared losses and not able to collect a positive MIPS adjustment?”

Great question, Robert.

There are, similarly, two potential gains for your Qualified Participants.

They are subject either to sharing savings or sharing losses.

As an ACO converts from one-sided to two-sided, with the agreement to share in potential losses, Medicare is willing to grant a bigger share of potential savings.

So, the net potential gain in shared savings in a two-sided MSSP ACO contract is bigger than in the one-sided MSSP ACO contract.

But that’s not all.

Whether they earn shared savings or shared losses, QP’s get an additional bonus for agreeing to participate in an Advanced APM:

• From the first year of the QPP through the 2024 payment year, QPs got a 5% positive adjustment on Medicare part B payments paid as a lump sum.
• For the 2025 payment year, QPs get a 3.5% positive adjustment on Medicare part B payments paid as a lump sum.
• For the 2026 payment year, QPs get a 1.88% positive adjustment on Medicare part B payments paid as a lump sum. PLUS, they get a better conversion factor on the Physician Fee schedule than do their peers who are not QPs.

Note that the adjustments are static, not based on scoring, independent of shared savings and losses, and always positive. Unlike MIPS scoring that has never been higher than about 2% and can just as easily be negative in any year.

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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