QPP Virtual Groups

QPP Virtual Groups...

Window Too Short for Most

December 31, 2017 deadline for 2018 action

 I had to listen in wonder to CMS'  first educational conference on QPP Virtual Groups on Tuesday, November 21st.  How did we get to the place where physicians have to make a decision on payment in less than six weeks while the comment period is still open till January 2, 2018?  I wonder how many small physician practices were able to take time from their office hours, two days before a holiday, to understand how changes to Medicare's Quality Payment Program (QPP) for year 2 (CY2018) will impact their Medicare reimbursement for 2020? How many have taken the time to read CMS' guidance for year 2, released on November 2nd (and pending a 90-day comment period that ends on January 2, 2018)?

I have followed MACRA and the QPP for the past year and a half with multiple articles and series on the impact. I was excited to hear more about how small physician practices could band together to tackle the requirements to report their outcomes, gain bonuses and avoid penalties for the coming years.  I embrace the idea of value-based payment reform.  I just think CMS has poured salt in the wound with the current timetable for implementation.

I have summarized the new year 2 guidance (in the sidebar article on this page: More on QPP YEAR 2...), the rules for virtual groups, and the frustration of having a short window to analyze what it means for 2018. For full details, visit the QPP.CMS.gov website and click to download the ZIP file called Virtual Groups Toolkit. Also, CMS has moved the QPP Resource Library to a new URL.  The QPP Year 2 Fact Sheet provides information on the Final Rule for 2018.

What defines QPP Virtual Groups?

The QPP initially allowed MIPS-eligible practitioners to submit under their personal (NPI) or group taxpayer identification number (TIN).  In Year 2 (CY 2018), a group of 1-10 clinicians under a unique TIN may join with one or more other unique TIN practitioners to form a new QPP Virtual Group.  Each participating TIN in a virtual group must meet the following criteria:

  • Virtual Groups must consist of two or more TINs.  There is no maximum limit.
  • Each TIN must have 1 and not exceed 10 clinicians.
  • Can participate if the TIN includes:
    • Clinician types eligible for MIPS:
      • Physicians
      • Physician assistants
      • Nurse practitioners
      • Clinical nurse specialists
      • Certified registered nurse anesthetists
      • Group that includes any of these clinicians.
    • Solo practitioner who exceeds the low-volume threshold (see sidebar article), AND is not a newly-enrolled Medicare provider, a Qualifying APM Participant (QP), or a Partial QP not choosing to participate in MIPS.
    • Group that exceeds the low-volume threshold at the group level (i.e. the NPIs within the TIN collectively exceed $90,000 and 200 Part B beneficiaries in a year.
  • A TIN can only participate in one (1) virtual group.
  • If a group chooses to join a virtual group, then all the eligible clinicians in that TIN must be included in the virtual group.
    • A whole TIN participates in a virtual group, including each clinician with an NPI within that TIN.
    • The whole TIN will be assessed and scored together as part of the virtual group, but only the clinicians in the TIN who are eligible for MIPS can get a MIPS payment adjustment.
    • TIN sizes are based on how many NPIs bill under a TIN, including those who don't meet the definition of a MIPS eligible provider.

QPP Virtual Groups will submit one set of data for the entire group.  While various types of clinicians might form a virtual group, they still must rely on one data set for each performance category.  This may make it difficult for some types of clinicians to report and meet performance standards, especially across various medical specialties.

The election period for QPP virtual groups began on October 11, 2017 and ends on December 31, 2017. CMS has established QPP Technical Assistant representatives to help clinicians access help on whether they may participate in a virtual group. Those who decide to proceed will need to set up formal agreement documents with all participants (template available in the QPP Virtual Groups Toolkit) and submit them via email to MIPS_VirtualGroups@cms.hhs.gov no later than December 31, 2017.

The Conundrum on QPP Quality Groups

With only a month left before the December 31st deadline to elect to join a QPP virtual group, clinicians need to do their due-diligence on the following questions:

  • Am I a MIPS-eligible clinician?
    • Remember, the low-volume threshold has increase to $90,000 (up from $30,000) or 200 Medicare Part B beneficiaries (up from 100).
  • Is a virtual group an option for me?
  • Is there other TINs that want to form a virtual group with whom I can work?
    • Can I identify them before the end of the year?
    • Can we agree what measures we will summit in each performance category?
    • Are those measures that I can meet?

Many physicians and clinicians will find it difficult to learn and process these questions before the end of the year.  Each TIN will need to consider the potential risks and benefits of QPP virtual groups.  Please see the sidebar article discussing some of the new twists to the QPP for Year 2.

Examples of Year 2 Impact including QPP Virtual Groups and 5% haircut
QPP Virtual Groups will be the new option for Year Two of Medicare's QPP.

More on QPP YEAR 2...

Your Opportunity to Comment

CMS released their final rule for QPP Year 2 on November 2nd.  However, these are open for public comment through January 2, 2018.  They have made a few changes in CY2018 based on over 1,200 stakeholder comments on the program.

  • Making Year 2 another "transition year" and delaying full impact of QPP penalties to Year 3.  (Remember your Year 2 actions determine your 2020 Medicare fee schedule.
  • Raising the exclusion criteria for low-volume Medicare providers:
    • Excluding individual MIPS (merit-based incentive payment systems) eligible clinicians or groups at or below $90,000 Part B allow charges, OR
    • Excluding those with 200 or less Part B beneficiaries in prior year.
  • Creating a Virtual Groups model option for practices with 10 or fewer providers.
  • Making it easier for providers to quality for incentive payments in Advanced APMs (alternative payment models) that begin or end in the middle of a year.

Highlights of the Year 2 MIPS Transition Year

The following changes apply to those who are using 2018 as another transition year to avoid the Year Two 5% penalties:

  • The performance threshold is raised to 15 points in Year 2 (from 3 points in the transition year).
  • Allowing the use of 2014 and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 and giving a bonus for using only the 2015 CEHRT.
  • Giving up to 5 bonus points on your final score for treatment of complex patients.
  • Automatically weighting the Quality, Advancing Care Information (ACI) and clinical practice Improvement Activities (CPIA) performance categories at ZERO (0%) of the final score for clinicians impacted by hurricanes Harvey, Irma and Maria, and for other natural disasters.
    • Clinicians impacted by the hurricanes will not be penalized in 2019 for failing to submit their MIPS data.
  • Adding 5 bonus points to the final scores of small practices.
  • Allowing small practices to form QPP Virtual Groups.
  • Adding a new hardship exception for the ACI performance category for small practices.

In addition, the 21st Century Cures Act was enacted in 2016 after Year 1 QPP final rules were in place.  This allows MIPS-eligible clinicians who are based solely at an ambulatory surgery center (ASC) and those who are hospital based AND can show significant hardship to weigh their ACI performance at ZERO (0%) as well.

Check out our MACRA QPP Glossary

Doctor: Click Here to See if QPP Applies to You

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