Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Exploring Virtual Groups in the Quality Payment Program, MIPS

Virtual groups allow independent physicians and small practices to pool their resources to successfully participate in the Quality Payment Program and MIPS.

Virtual groups, Quality Payment Program, and Merit-Based Incentive Payment System (MIPS)

Source: Thinkstock

By Jacqueline LaPointe

- Virtual groups enable independent physicians and clinicians in small practices to participate in Medicare’s historic push to transition to value-based reimbursement: the Quality Payment Program.

The Quality Payment Program, or QPP, aims to shift the industry away from fragmented fee-for-service payments to a system that reimburses clinicians based on the value of the care they deliver. Through the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models, the program ties an eligible clinician’s Medicare reimbursement to care quality and cost performance.

However, like most value-based reimbursement models, the QPP creates challenges for independent physicians and small practices.

Current alternative payment models require extensive practice transformations that can cost practices thousands, if not millions, of dollars. On top of substantial investments, providers in solo or small practices may find their quality performance significantly skewed by their low patient volumes.

Despite the challenges, Medicare requires certain clinicians to participate in the Quality Payment Program’s Merit-Based Incentive Payment System.

READ MORE: Developing a 2018 MIPS Reporting Strategy to Avoid a Penalty

Medicare requires physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who meet the low-volume threshold to participate in MIPS for the 2018 performance period.

Leaders of the federal healthcare program only expect QPP participation to expand as the industry transitions to value-based reimbursement. CMS recently proposed adding new clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists), as well as finalizing a third element to the low-volume threshold determination.

But eligible clinicians in solo or small practices that barely meet the low-volume threshold can successfully participate in the QPP through a virtual group.

Virtual groups allow independent physicians and small practices to band together for QPP participation. Combining quality data, collectively reporting performance information, and sharing resources are among the top benefits of participating in a virtual group.

In the following, RevCycleIntelligence.com explores the basics of virtual groups, as well as how solo doctors and small practices can form a group, report their data to the QPP, and reap the benefits of group QPP participation.

What is a virtual group?

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

A virtual group is a combination of two or more Tax Identification Numbers (TINs) assigned to one or more solo practitioners who are eligible to participate in the QPP’s Merit-Based Incentive Payment System (MIPS) or to one or more groups consisting of 10 or fewer clinicians (including at least one MIPS eligible clinician), or both. The providers choose to form a group for a QPP performance period.

Eligible clinicians who can participate in a virtual group include MIPS eligible solo practitioners who exceed the low-volume threshold, are not new Medicare providers, and are not participating in a qualifying alternative payment model.

Small practices that exceed the low-volume threshold at the group level and have 10 or fewer clinicians that have reassigned their billing rights to the TIN can also participate in a virtual group. However, the practice must employ at least one MIPS eligible clinician.

The low-volume threshold during the 2018 performance was $90,000 or less in Physician Fee Schedule services furnished to Medicare Part B fee-for-service enrollees or 200 or fewer Medicare Part B fee-for-service enrollees treated.

CMS plans to add another low-volume threshold determination in the 2019 performance year. The federal agency may require eligible clinicians to deliver at least 200 covered professional services to participate in MIPS.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

Virtual groups do not have clinician type requirements. Participants in the group have the flexibility to determine their own composition and there are no requirements based on specialist or locality, CMS states.

The federal agency also did not include a limit on the number of TINs that can be part of a virtual group.

However, solo practitioners are restricted to participation in just one virtual group during a performance period.

Forming a virtual group

Once independent physicians and small practice leaders decide on virtual group participation, the providers must go through a two-stage election process.

The first stage is optional and includes contacting a provider’s QPP Technical Assistance organization. The QPP Technical Assistance organization can provide more information on TIN size to help providers figure out if they meet the criteria to join or create a virtual group.

The second stage of the virtual group election process starts with providers creating a formal, written agreement. Each solo practitioner and practice within the virtual group must sign the agreement before the group submits their election application to CMS.

According to CMS, the virtual group agreement must:

  • Identify the parties of the agreement by name, TIN, and National Provider Identifier (NPI)
  • Require each TIN to notify all NPIs associated with the TIN of their virtual group participation
  • Mandate each member to participate in MIPS as a virtual group and comply with MIPS requirements and other applicable laws and regulations (e.g., False Claims Act, HIPAA, and physician self-referral law)
  • Define the NPI’s rights and obligations in the virtual group, including reporting requirements and how participation in the virtual group impacts the NPI’s participation in MIPS outside of the virtual group
  • Describe how the payment adjustment component of MIPS will incentivize each virtual group member to adhere to quality assurance and improvement
  • Require each member to update its Medicare enrollment information (e.g., the addition or subtraction of NPIs billing through its TIN) in a timely manner and to notify the virtual group of any such changes within 30 days
  • Define the agreement term as at least one QPP performance period
  • Mandate completion of a close-out process upon agreement termination or expiration that requires each member to deliver all data necessary for the virtual group to collect data
  • Be executed on behalf of each member by an authorized individual

Virtual groups do not need to submit the agreement to CMS as part of the election process.

Naming an official virtual group representative and submitting the group’s election are the next steps in the second stage of the election process. The official representative must submit the virtual group’s election via email to CMS before the start of the next performance period.

QPP performance periods end on December 31. Therefore, CMS must receive elections prior to December 31 to approve virtual group participation.

Once virtual groups complete the second stage, CMS will approve or reject virtual group applications and notify applicants.

How do virtual groups submit QPP data, receive scores?

Participating in the QPP through a virtual group allows independent physicians and small practices to gather enough patient cases to be reliably measured and scored, CMS explains. Therefore, outlier patients, like medically complex individuals or those with exceedingly high costs, do not skew a provider’s performance in MIPS.

The virtual group also allows the independent doctors or small group to pool their resources and expertise to boost their MIPS performance in the QPP.

The catch is reporting MIPS data as a group. Virtual groups collect and report performance data at the virtual group level, and Medicare also assesses the information and gives performance scores at the virtual group level.

To successfully participate as a virtual group, each group must collect QPP performance data from all the TINs within the virtual group. Medicare does not facilitate data aggregation.

Virtual groups can leverage the technology of their peers for data collection or use a third-party intermediary.

Like eligible clinicians reporting as individuals, virtual groups can submit their QPP data using their EHR system, qualified clinical data registries, and qualified registries.

The groups can also use the CMS Web Interface and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey as long as the group meets the clinician requirements. Virtual groups must have at least two eligible clinicians to use the CAHPS for MIPS survey and at least 25 eligible clinicians to submit data using the CMS Web Interface.

Prior to forming a virtual group, Medicare recommends that independent physicians and small practices ask the following MIPS reporting questions:

  • How would the virtual group meet the requirements for each of the four MIPS performance categories?
  • Are there operational issues that the group would need to address to meet each performance category’s reporting requirements?
  • Which measures and activities would the group report?
  • How would the group collect and aggregate data?
  • Which submission mechanism or mechanisms would the group use?
  • What health IT systems do others in the group use?
  • How would the group identify and share best practices?
  • What processes, workflows, and other tools are needed to prepare the group for reporting?
  • How would each TIN within the group share decision-making responsibilities?
  • Has the group developed a strategic plan and timeline?
  • Has the group determined if, how, and when the TINs in the group would be able to view QPP data?

Medicare will assess and score the MIPS performance data as a group. Providers in the virtual group will receive the group’s score and only MIPS eligible clinicians will receive the payment adjustment associated with that score.

Participating in the Quality Payment Program and other value-based reimbursement models are a challenge for independent physicians and small practices operating with tight margins and lower patient volumes.

But virtual group participation in the QPP can help providers pool their resources and successfully participate in one of the largest value-based reimbursement programs out there.

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