Practices that fail to submit the proper reporting data to the Centers for Medicare and Medicaid Services (CMS) by the reporting deadline could face significant financial consequences. However, those that do meet the reporting requirements stand to benefit financially in the upcoming years.

Reporting Responsibilities: ACO vs. Practice

Practices that belong to an accountable care organization (ACO) are responsible for the following three reporting categories:

  • Improvement Activities
  • Promoting Interoperability
  • Cost

Generally, ACOs report on quality metrics, but practices should never assume this to be the case. It is always better to confirm with the ACO which categories it will report on.

Furthermore, practice leaders should inquire how much data the ACO collects, how timely it utilizes the data and if these services incur an extra fee. With this understanding, practices can move forward and make informed decisions about what they will report each year.

As CMS and payers develop incentive programs, providers need robust analytics

Related Article: As CMS and payers develop incentive programs, providers need robust analytics

Merit-based incentive payment system (MIPS) reporting is complicated, but it does not have to be a burden on your practice. When you have the right analytic tools for the job, you can meet reporting requirements easily. To learn more, speak with an expert consultant at Tangible Solutions today.

New ACO Incentives

Reporting quality data properly helps ACOs avoid significant financial losses, allowing them to maintain quality of care while saving money. Medicare updated its Physician Fee Schedule (PFS) in 2023 to encourage greater ACO participation. The 2023 Medicare PFS now advances payments to smaller rural ACOs to help with upfront investments such as new technology, increased staffing and improved infrastructure.

The Importance of Paying Close Attention to MIPS in 2024

Back in 2017, practices got a pass when it came to MIPS reporting. ACOs took on all of the responsibility for reporting to CMS. However, this changed in 2018. Essentially, an ACO has a separate contract with CMS, which only covers one of the MIPS reporting areas. Practices are responsible for the rest.

In 2019, primary MIPS reporting responsibilities shifted from ACOs to practices. Though a few ACOs may help their partner practices collect and report MIPS data, this is far from common. Practices that had not yet started to collect reporting data had to do so before the end of 2019 or risk taking a hit to their reimbursements in 2020.

Since 2020, practices have had to decide if they want to merely avoid the negative payment penalty or go for the full 5% reward. To avoid the penalty, practices must earn a minimum of 15 points. Each measure carries with it a potential points score, and there are opportunities to earn bonus points. For example, if a measure is labeled as a high priority, it may carry additional points. Meanwhile, small practices — defined as employing between one and 15 clinicians — automatically gain five bonus points.

To have the best chance of receiving the full reimbursement adjustment, practices should consider splitting up their efforts among each reporting category. Obviously, quality reporting carries the most weight, so if a practice is unable to participate in each category, quality is the one to choose.

Reporting in 2024

It is important to note some changes to reporting in the upcoming years. CMS proposed a new Medicare Physician Fee Schedule (PFS) rule in 2023, and it will go into effect in 2024. This rule’s purpose is to help ACOs shift to a digital quality data measurement approach. Under this new 2024 rule, ACOs can use Medicare CQMs to report the following quality measures on their Medicare beneficiaries only:

  • Controlling High Blood Pressure (#236)
  • Preventive Care and Screening: Screening for Depression and Follow-up Plan (#134)
  • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (#1)

The Shared Savings Program requires ACOs to report the above Medicare CQMs. However, ACOs can also meet the Shared Savings Program’s quality data reporting requirements by combining the following collection types in 2024:

  • eCQMs
  • MIPS CQMs
  • Medicare CQMs
  • CMS web interface

ACO must rely on other collection types: eCQMs, MIPS CQMs, and Medicare CQMs

The CMS web interface will become unavailable for quality data after next year, so ACOs must rely on the other three collection types by 2025. ACOs will receive an annually updated list from CMS, indicating which patients are eligible for Medicare CQMs. On this list, ACOs can find the minimum data required to report Medicare CQMs, which includes the following:

  • Beneficiary identifier
  • Date of birth
  • Date of death if necessary
  • Gender
  • Chronic condition subgroup
  • ACO frequented providers’ NPIs
  • Health status details to help identify individuals who meet Medicare CQM requirements

It is important to note that, on the annual list, CMS only provides some of the beneficiaries ACOs should include in their Medicare CQM quality data reporting. ACOs must ensure they include all patients who meet Medicare CQM requirements.

2024 ACO REACH Changes

The Realizing Equity, Access, and Community Health (REACH) ACO model will also undergo changes in 2024. These changes aim to increase stability, predictability and health equity within the model. Expect to see the following changes:

  • Reduced beneficiary alignment fluctuations
  • Reduced beneficiary alignment minimum escalation
  • Eligibility criteria refinement for High Needs Population ACO alignment
  • Provisional settlement update
  • Financial guarantee policy modification
  • Symmetric risk corridor application to Retrospective Trend Adjustment (RTA)
  • Risk adjustment methodology adjustments
  • Pulmonary rehabilitation expansion to physician assistant (PA) and nurse practitioner (NP) Benefit Enhancement (BE) services
  • Health Equity Benchmark Adjustment (HEBA) composite measure revision
  • Expanded HEBA access

The ACO REACH model began in 2023 and is expected to remain through 2026. CMS will add a 10% buffer on all ACO types’ alignment minimums. The provisional settlement will cover performance experience over 12 months rather than the previous 6-month span. Additionally, CMS will add three symmetric risk corridors to the RTA, and it will revise the risk adjustment methodology using the following scores:

  • 67% of the 2020 risk adjustment model’s scores
  • 33% of the revised model’s scores

Expanding HEBA access increases its impact, and adding the pulmonary rehabilitation expansion to BE services improves patient care. These changes increase health equity and address previous concerns in ACO reporting.

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Case Study: MIPS Reporting Made Less Stressful

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