Previously, we highlighted several advantages of participating in the Medicare Shared Savings Program (MSSP) as an accountable care organization (ACO).  Our list included the more favorable manner in which a physician’s score is calculated under the Merit-Based Incentive Payment System (MIPS) if he or she is part of a Track 1 (no downside risk) MSSP ACO.

Although such an ACO does not qualify as an Advanced Alternative Payment Model under the new Medicare Quality Payment Program, and thus does not exempt its participating physicians from MIPS, these physicians are excused from many of the MIPS reporting requirements.  Instead, CMS will apply the APM Scoring Standard, using the ACO’s scores on the MSSP performance measures to calculate their MIPS scores.

As seems to be the case with all things MIPS, the regulations regarding the APM Scoring Standard can be challenging.  We have prepared the following summary to help providers understand this new benefit of participating in a Track 1 MSSP ACO.

  1. Background
  • MIPS scores are assigned at the TIN/NPI level. If an Eligible Clinician (e., a physician or non-physician practitioner who is subject to MIPS) bills for services under multiple TINs, he or she will receive a separate MIPS score for each TIN.
  • For purposes of the MSSP, an “ACO Participant” is a Medicare-enrolled healthcare provider identified by its TIN (or, in the case of a solo practitioner, his or her NPI) that has signed a Participant Agreement with an MSSP ACO.
  • Each ACO Participant is responsible for informing the ACO of any additions or deletions to the list of physicians and non-physician practitioners for whom the ACO Participant bills Medicare Part B services under its TIN. The ACO uses this information to regularly update its ACO Provider/Supplier List with CMS.
  • If an Eligible Clinician’s name appears on the ACO’s Provider/Supplier List as of March 31, June 30, or August 31 of a performance year, CMS will calculate that Eligible Clinician’s MIPS score for that performance year for services billed under the TIN of the ACO Participant using the APM Scoring Standard.
  • All Eligible Clinicians whose names appear on the ACO’s Provider/Supplier List on one of the three aforementioned dates in 2017 will receive the same MIPS score, and will be subject to the same payment adjustment in 2019 with regard to services furnished under an ACO Participant’s TIN. Stated another way, the MIPS score is calculated at the ACO level.  An Eligible Clinician cannot elect to report individually, nor can an ACO Participant report as a group to earn a higher score.
  • If an Eligible Clinician also bills for services under another TIN that is not an ACO Participant, the MIPS score for that TIN/NPI will be calculated in the usual manner.
  1. Mechanics

Under the APM Scoring Standard, MIPS scores are calculated as follows:

MIPS MSSP Graph

This formula will not change from year-to-year; the cost component never will be included in the calculation.  (This is different from the standard MIPS formula, which will introduce the cost component at 10% in 2018, growing to 30% in 2019.)

  1. Quality Component. CMS will calculate the ACO’s quality score based on the measures submitted by the ACO through the CMS Web Interface as required by the MSSP.  The other components of the ACO’s MSSP quality score – the CAHPS survey and the measures calculated by CMS using claims and administrative data – are not considered for purposes of the ACO’s MIPS quality score.  No separate individual or TIN-level group reporting is required.
  1. Clinical Practice Improvement Activities Component. CMS will credit the ACO with the maximum score for this component based on its participation in the MSSP.    No separate individual or TIN-level group reporting is required.
  1. Advancing Care Information (ACI) Component. Each ACO Participant must submit its physicians’ scores on the required measures to CMS.  CMS then will aggregate all ACO Participants’ scores as a weighted average based on the number of Eligible Clinicians under each TIN, yielding the ACO’s score under this component.

Each ACO Participant must utilize the group reporting option for the Advancing Care Information Component.  Specifically, the ACO Participant will need to aggregate and report performance on the required ACI measures for all non-hospital-based physicians for whom the ACO Participant has data in CEHRT.

  • A physician is “hospital-based” if ≥ 75% of Medicare Part B services billed under the ACO Participant’s TIN for that physician have listed as the site of service inpatient (21), on-campus hospital outpatient department (22), or emergency department (23).
  • Non-physician practitioners are excluded from the Advancing Care Information component.
  • An ACO Participant should include all non-hospital-based-physicians listed on the ACO Provider/Supplier list as of March 30, June 30, or August 31 of the performance year.

For organizations struggling to understand and address the impact of MIPS, participation in an MSSP ACO may kill two birds with one stone:  it minimizes MIPS worries, and it prepares organizations for participation in risk-based alternative payment models.

For more information on MIPS or the MSSP, contact Martie Ross at (800) 270-9629.