In this episode, Dr. Dan Mingle answers listener questions about moving patients between ACOs, the changing dynamics of APM bonuses and if partial QPs should submit MIPS instead, clarifying the requirements for self-submission of Medicare CQMs, and the potential impacts of federal government turmoil on the Quality Payment Program.

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

Question One: Moving Patients from One ACO to Another

Stacy asks: “Is there a way to move patients from one ACO to another without having to gain claims attribution? We have two ACOs and want to move patients from one to the other without losing data.”

Great question, Stacy. There are three main factors that can influence patient attribution movement from one Accountable Care Organization (ACO) to another. Which of these you can leverage depends on your specific circumstances.

Attribution rules can vary slightly based on contractual choices and more significantly between different Center for Medicare and Medicaid Innovation (CMMI) programs. In general, the following dynamics are in play:

• 1. Patient Choice:
  • Medicare beneficiaries can log into MyMedicare.gov and designate their preferred provider as their primary care provider (PCP).
  • Patients are attributed to the Taxpayer Identification Number (TIN)-practice where their chosen provider practices.
  • This is the highest priority step in attribution analysis.
• 2. Plurality of Care from a Primary Care Provider:
  • Medicare counts encounter-visits for primary care services delivered by a PCP.
  • Primary Care Services: Typically include most or all of the Evaluation & Management (E&M) codes from the list of billable CPT or HCPCS codes. This list is updated periodically.
  • Primary Care Specialties: Include family practice, internal medicine, geriatric medicine, general practice, and their subspecialties.
  • Attribution is based on a plurality of care. Each patient is attributed to the TIN-practice that delivered the highest number of primary care codes by primary care providers to that individual patient.
• 3. Attribution to Other Specialists:
  • This is used only if no PCP provides at least one primary care visit.
  • Patients can be attributed to other specialists (not generally considered PCPs) if they billed for at least one primary care type of visit.

With that background, let’s specifically address your question, Stacy. The answer depends on how you are moving those patients:

• If the TIN-practice has left one ACO and joined another: Their attributed patients generally come with them. No re-alignment action is required.
• If one or more providers have left a TIN-practice in one ACO and joined a different TIN-practice aligned with another ACO: That provider’s patients will not automatically attribute to the new practice in the new ACO until an attributable action occurs.
  • Prospective Attribution: You can suggest or help your patients log in to MyMedicare.gov and select their PCP at the new practice.
  • Retrospective Attribution: Patients will be realigned once enough visits have occurred at the new practice to establish a new plurality of care.

Currently, I’m not aware of any bulk action or shortcut to expedite this process beyond these established mechanisms.

If this doesn’t fully address the challenge you’re facing, Stacy, please provide more particulars, and I’ll try to be more specific.

Question Two: Opting for Traditional MIPS Instead of APM Bonus

Steve shares: “It might be important to note that the APM bonuses, which were larger than those potentially provided by traditional MIPS, are now going away. We used to get a 5% lump sum bonus on Medicare payments for earning Qualified Participant (QP) status in an alternative payment model. The bonus is down to 3.5% in 2025 (based on 2023 APM attribution and QP status). It will go down to 1.88% in 2026 (based on 2024 attribution and QP status). Starting in 2027, the incentive will only be a 0.75% boost to the conversion factor on the physician fee schedule. It might be advantageous to be a partial QP, if possible, and submit traditional MIPS.”

Thanks, Steve, for that insightful observation. I like how you think. You found strategic value in partial QP status.

The key takeaway here is not to fear partial QP status, or even non-QP status, as there might be some advantages in certain situations. However, I stop short of recommending that you actively seek to avoid QP status. Here’s why:

• It’s not as easy as you might think to avoid QP status. QP status is indirectly a measure of patient engagement, which is pivotal to controlling healthcare costs and accessing the financial gains within whatever Alternative Payment Model (APM) you are participating in.
• MIPS incentives are not definitively better or easier to access than QP incentives.

For those unfamiliar with Qualified Participant (QP) status, let me explain:

When discussing Alternative Payment Models (APMs), I refer to the Medicare Shared Savings Program (MSSP) because it’s the most common, but these principles apply across all APMs. Every APM has a reward for healthcare cost savings.

QP status is granted to participants in an Advanced APM through Medicare’s Center for Medicare and Medicaid Innovation (CMMI). There are thresholds to achieve QP status and lower thresholds for partial QP status. Medicare measures your volume based on:

• Count of unique Medicare patients seen in a year.
• Total allowable charges submitted for Medicare patients in a year.

Medicare then compares these numbers to the subset of those patients attributed to your ACO. There’s a threshold percentage that Medicare has been slowly increasing.

For the 2025 performance year, the thresholds are:

QP Status:

• 50% of allowable charges OR
• 35% of the count of unique patients

Partial QP Status:

• 40% of allowable charges OR
• 25% of your unique patients

Achieving either threshold for the respective status in 2025 makes you a QP or partial QP for that year.

What does this mean for MIPS?

If you are a QP:

• You have no MIPS liability.
• You won’t get credit for a MIPS submission, even if you make one.

If you are a Partial QP:

• You can choose whether or not to participate in MIPS.
• Ideally, you submit if you expect to score well and earn an incentive.
• You might choose not to submit if you anticipate a negative payment adjustment.

If you are a Non-QP:

• You are liable for MIPS and will receive whatever MIPS incentive (positive or negative) you earn.

Regardless of QP status, all APM participants stand to benefit from APM rewards for cost savings, subject to your ACO’s participation agreement.

Why it’s not easy (or always advisable) to avoid QP status:

• High QP Achievement Rates: In 2022 (the most recent year with published statistics):
  • Out of ~420,000 advanced APM participants:
    • ~386,000 achieved QP status.
    • ~34,000 were non-QPs.
    • Only ~300 were partial QPs.
  • I suspect that:
    • Virtually all primary care providers become QPs due to the nature of patient engagement (patients returning to someone they know).
    • Those who don’t are likely in practices with unusual circumstances.
    • Most partial QPs and non-QPs are likely in specialty practices, where status is determined more by referral networks than direct patient engagement. If you predominantly get referrals from within your ACO, you’ll more likely be a QP.
• Avoiding QP Status is Detrimental to ACO Goals: Deliberately avoiding QP status often means avoiding seeing patients on a recurring basis, which signifies disengagement.
  • If an ACO doesn’t have engaged patients, it has limited influence to promote cost reduction.
  • For a PCP, low attribution (a measure of engagement) is generally a bad sign.
• MIPS Incentives Aren’t Guaranteed to Be Better:
  • In Advanced APMs, all QPs earn the APM incentive. This was true for the 5% bonus and will continue with the 0.75% conversion factor boost.
  • The 0.75% boost to the conversion factor means all payments for Medicare services (both Medicare payment and patient out-of-pocket) are higher. Compared to MIPS, this APM incentive is effectively closer to 1%.
  • MIPS incentives are revenue-neutral to CMS.
    • You can lose as much as 9% of Medicare payments.
    • While designed for potential gains up to 9% or more, I’ve rarely seen the highest positive adjustment exceed 2%.

If you participate in MIPS as an Advanced APM participant:

• You are unlikely to face large negative adjustments.
• Your APM’s quality submission (at least in MSSP) will count as your quality score unless a separate submission earns a higher score.
• You’ll earn 100% of your practice improvement points (all APM participants do).
• With the requirement for Certified Electronic Health Record Technology (CEHRT), you’ll either generate a Promoting Interoperability score or have an exception.
• The Cost category is waived for all APM participants because APMs inherently include mechanisms to respond to cost efficiencies or inefficiencies.

Question Three: Clarifying Requirements for Self-Submission of Medicare CQMs

Carrin shares: “Thank you for sharing this blog. I wanted to follow up on the answer to the first question. Dr. Mingle mentioned that to submit Medicare CQMs, we must be a Medicare-Qualified Registry, and the submission requires a valid Registry Identifier while following the process outlined in Medicare’s Qualified Registry Self-Nomination Toolkit. However, I wasn’t able to locate the specific CMS documents that state this requirement. Could you clarify where I can find the official CMS rules or website that confirm we must be a Qualified Registry to submit Medicare CQMs?”

Thank you for your challenge to my answer. It prompted me to revisit the QPP resource library and the Electronic Code of Federal Regulations to confirm the facts.

After reviewing, I believe you are likely correct: you may not need to have qualified registry status to submit your own quality measures directly.

• When Medicare launched quality reporting back in 2007 for the Physician Quality Reporting System (PQRS), it was explicitly clear that anyone submitting quality measures had to be qualified as a registry. I built my first registry for and within the community health system where I worked at the time.
• Sometime in the last 10 years, the rules appear to have quietly changed.

The current language isn’t as explicit as I’d like:

• It’s explicit that if you are a third-party intermediary, you must be qualified by Medicare as a Registry to submit quality measures on behalf of others.
• It’s implicit that if you are submitting for yourself (your own practice/organization), you are not subject to the same rules and requirements as qualified registries.

This could have been a deliberate change by CMS, or it could have been a gradual drift in language as institutional knowledge ages out of Medicare.

I would be more confident in this interpretation if I knew of anyone who has successfully made such a submission for their organization (MIPS CQMs or Medicare CQMs) without achieving Qualified Registry Status.

So, I’m posing this question to all of you:

Have you, or anyone you know, made a quality submission of MIPS CQMs or Medicare CQMs directly to CMS without achieving and maintaining Qualified Registry status? I know this is possible with electronic CQMs (eCQMs), but I’m specifically interested in your experiences with MIPS CQMs or Medicare CQMs submitted via other mechanisms.

Please share your experiences!

Question Four: How Turmoil in the Federal Government Affects the Quality Payment Program

David asks: “How is the current turmoil in the federal government going to affect the Quality Payment Program (QPP)?”

Great question, David. We are certainly living in uncertain times regarding federal programs and the enforcement of federal rules.

Whether you are a MIPS participant or involved in one of CMMI’s APMs, there have already been changes, and more could come. This is a volatile situation, and things can change quickly.

Current Status:

• Medicare continues to function, paying for care as they normally do.
• The Merit-Based Incentive Payment System (MIPS) and the Medicare Shared Savings Program (MSSP) are still fully operational.
• We are well underway in the 2025 performance year.

Changes we’ve seen so far:

• Medicare has canceled a couple of the mandatory monthly meetings they’ve held for the last 18 years to manage their Qualified Registries.
• CMMI has brought four programs to an early closure:
  • Maryland Total Cost of Care Model
  • Primary Care First Model
  • ESRD Treatment Choices Model
  • Making Care Primary Model
• Sweeping layoffs in the Department of Health and Human Services are expected.

It’s hard to be certain what will be required as 2025 concludes and we enter the submission season in the first quarter of 2026 for our 2025 data.

My Expectations (Not Guarantees):

• I do not expect to see changes to the core Medicare programs. Medicare is the world’s largest healthcare insurance program, and the United States depends on it. Damaging these programs would likely amount to political suicide. This assessment includes:
  • Medicare Part B (the physician payment program)
  • Medicare Part A (the hospital payment program)
  • Medicare Part D (the drug payment program)
  • Medicare Advantage
  • The Merit-Based Incentive Payment Program (MIPS)
  • The Medicare Shared Savings Program (MSSP)
• Plan for Business as Usual:
  • You should plan to continue your operations as normal. Provide care, generate bills, participate in quality reporting, and advance your use of CEHRT. Do not expect any easing of requirements.
• There may be a general slowdown of service and programmatic evolution:
  • For MSSP users, the Web Interface is gone. I don’t expect Medicare to have the resources or will to revive it.
  • I anticipate less activity than usual in the proposed and final rules for the physician fee schedule (which includes most rules for MIPS, MSSP, and CMMI).
  • There will likely be less evolution in MIPS Value Pathways or new CMMI APM models.
• There could be delays in service and attention:
  • At the QPP help desk
  • And in individual attention to Extreme and Unusual Circumstances (EUC) applications
  • And in Focused Review requests
    • These service lapses could work to your advantage (e.g., more rubberstamping of requests) or to your disadvantage (e.g., rapid judgments and immovable “no” decisions).

It’s probably not the best time to start participating in a brand-new program, build a new ACO, or join a new CMMI program until the situation stabilizes.

The safest approach is to expect no change to your current requirements.

Even if changes are announced, we’ve seen enough volatility that an announcement one day might be canceled the next. Don’t trust changes until it’s too late to reverse your course based on them.

Continue your essential activities:

• Provide great care.
• Continue to collect and save your data.
• Continue to improve your EHR functionality.
• Plan for continued compliance and submissions.

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?

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