MIPS 2018: The Reality of Virtual Groups

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Posted By: Industry Expert December 4, 2017

By Dr. Pawan Jindal, Founder, MyMipsScore
Twitter: @MyMipsScore

There are generally two ways to participate in MIPS in 2017: as an Individual or as a Group. Beginning 2018, there will be a third option available to individuals and small groups called the “Virtual Group”. The definition of Virtual Group comes from the definition of ‘virtual’ and ‘group’. Virtual means near or implied and group refers to the MIPS definition of group. So, Virtual Groups would generally be treated under MIPS as groups with few variations. The goal of Virtual Groups is to provide a comprehensive measurement of performance, shared responsibility, and an opportunity to effectively and efficiently coordinate resources to achieve requirements under each performance category. In this blog, we will discuss some of the variations to help you determine why you may (or may not) want to join a Virtual Group.

Virtual Group Formation
Any individual MIPS eligible clinician or a group of 10 or fewer clinicians can form a Virtual Group with at least one other such individual eligible clinician or group.

  • Each participating individual clinician must meet the the low volume threshold definition of MIPS Eligible clinician. That is, have greater than $90,000 in Medicare Part B allowed charges AND care for more than 200 Medicare Part B patients.
  • Each participating group also has to meet the low volume threshold requirements at the group level. A group may have clinicians that do not meet the low volume threshold requirements at individual level. However, there must be at least one MIPS eligible clinician in the group.

A Virtual Group election process requires a formal written agreements among individual clinicians and groups electing to form a Virtual Group. CMS has provided guidelines on the election process as part of the 2018 Virtual Group Toolkit available on the QPP website.

A Virtual Group will select a Virtual Group representative. This person would make the election on behalf of the members of a Virtual Group regarding the formation of a Virtual Group for the applicable performance period, by the election deadline. Virtual Groups have until December 31, 2017 to make the election for 2018 performance year.

The key things to remember are:

  • A Virtual Group is created for at least one performance period. Participants are NOT allowed to change the selection during the performance period.
  • An individual or a group may only participate in one Virtual Group during a performance period. This is determined at the TIN level.
  • There is no limit to number of participants in a Virtual Group
  • Virtual Group is recognized as an official collective entity for reporting purposes but is not a distinct legal entity for billing purposes. As a result, Virtual Group will not need to establish a new TIN nor reassign their billing rights to a new or a different TIN. Not requiring a separate TIN will keep the administration simple. Virtual Groups would be identified by a Virtual Group Identifier. Going forward, each clinician under the Virtual Group will then be uniquely identify by the combination of the 3 identifiers – Virtual Group Identifier, TIN, and NPI. Virtual Identifier will be required submit MIPS data.

Virtual Group MIPS Reporting Requirements
Most of the reporting requirements applicable to groups would also generally be applicable to Virtual Groups, unless otherwise specified.

  • Virtual groups will aggregate data for each NPI under each TIN within the virtual group by adding together the numerators and denominators to report the measure ratio for a measure at the Virtual Group level.
  • Most of the quality measures reporting requirements such as requiring 6 measures including one outcome measure or high priority would apply to Virtual Group. All Cause Hospital Readmission Measure would be included if the Virtual Group has more than 15 clinicians and meets the case volume of 200 cases.
  • Data completeness requirements for Virtual Groups would apply cumulatively across all TINs in a Virtual Group. If the Virtual Group has one TIN that falls below the 60 percent data completeness threshold for measure, they may still report on that measure as long as the Virtual Group cumulatively exceeds such threshold.
  • Virtual Groups submitting quality measures data using the CMS Web Interface or a CMS approved survey vendor to report the CAHPS for MIPS survey must meet the data submission requirements on the sample of the Medicare Part B patients CMS provides.
  • ACI data for Virtual Groups will be aggregated by combining data from Certified EHR Technology from all participants. If the groups (not including solo practitioners) that are part of a Virtual Group have CEHRT that is capable of supporting group level reporting, the Virtual Group would submit the aggregated data across the TINs produced by the CEHRT. If a group (TIN) that is part of a Virtual Group does not have CEHRT that is capable of supporting group level reporting, such group would aggregate the data by adding together the numerators and denominators for each MIPS eligible clinician within the group for whom the group has data captured in CEHRT. If an individual MIPS eligible clinician meets the criteria to exclude a measure, their data can be excluded from the calculation of that particular measure only.
  • Virtual Groups have been provided with some flexibility as to the method for counting unique patients in the denominators to accommodate such scenarios where aggregation may be hindered by systems capabilities across multiple CEHRT platforms. When aggregating performance on advancing care information measures for Virtual Group level reporting, CMS does NOT require that a Virtual Group determine that a patient seen by one MIPS eligible clinician (or at one location in the case of TINs working with multiple CEHRT systems) is not also seen by another MIPS eligible clinician in the TIN that is part of the Virtual Group or captured in a different CEHRT system.
  • For the improvement activities performance category, a Virtual Group would meet the reporting requirements if at least one NPI within the Virtual Group completed an improvement activity for a minimum of a continuous 90-day period within CY 2018.

Virtual Group MIPS Score
The Virtual Group MIPS Score will be calculated by combining the scores of all the performance categories using the score calculation rules applicable for MIPS groups. Each eligible clinician in a Virtual Group will receive this Virtual Group score that will be reflective of the combined performance of the Virtual Group.

MIPS Special Considerations
The requirements for meeting some of special considerations defined under MIPS would apply to Virtual Groups as follows:

  • Certified or recognized patient-centered medical home or comparable specialty practice under the improvement activities performance category: At least 50 percent of the practice sites within the TINs of Virtual Groups will be required to be recognized or certified as a patient-centered medical home or comparable specialty practice.
  • Non-patient facing: More than 75 percent of the NPIs billing under the Virtual Group’s TINs should meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period.
  • Small practice: The Virtual Group consists of 15 or fewer eligible clinicians would be eligible for small practice consideration under MIPS.
  • Rural area or HPSA practice: The Virtual Group’s TINs may be designated as rural areas or HPSA practices if more than 75 percent of NPIs billing under the Virtual Group’s TINs are designated in a ZIP code as a rural area or HPSA.

MIPS scoring rules applicable for the special considerations above would also apply to Virtual Groups. As an example, a Virtual Group would need to submit four medium-weighted or two high-weighted activities for a minimum of a continuous 90-day period in CY 2018 to achieve full credit under the improvement activities performance category for the 2018 performance period. Virtual Groups that are considered to be non-patient facing or small practices, or designated as rural or HPSA practices will receive full credit by submitting one high-weighted improvement activity or two medium weighted improvement activities that were conducted for a minimum of a continuous 90-day period in CY 2018.

Payment Adjustments for Virtual Groups
The Virtual Group MIPS Score would be applied to all TIN/NPIs billing under a TIN included in the Virtual Group during the performance period. The payment adjustments would be applied at the TIN/NPI level based on the Virtual Group Score.

Clinician participating in Advanced APM: The clinicians who are a part of a Virtual Group, but are also Qualified Participants (QP status) in an Advanced APM, will have their performance counted as a part of the Virtual Group, but will not receive payment adjustment based on the Virtual Group MIPS score. These clinicians’ payment adjustment will be covered under the Advanced APM entity.

Clinician participating in MIPS APM: The MIPS-APM entity’s score will determine the payment adjustment instead of the Virtual Group score for the MIPS eligible clinicians who are participating both in a Virtual Group and a MIPS-APM entity.

When Plans Change
In the case of a TIN within a Virtual Group is acquired or merged with another TIN, or no longer operating as a TIN (for example, a group practice closes), during a performance period, such solo practitioner’s or group’s performance data would continue to be attributed to the Virtual Group. The remaining parties to the Virtual Group would continue to be part of the Virtual Group even if only one solo practitioner or group remains.

This article was originally published on MyMipsScore and is republished here with permission.