Physicians participating in Medicare’s Merit-based Incentive Payment System (MIPS) have the option of reporting data for 2018 as an individual Eligible Clinician (EC), as part of a group practice that bills Medicare using the same Taxpayer ID Number (TIN), or as part of a Virtual Group. The latter option is available to a group with 10 or fewer ECs, or an EC in solo practice, who might want to join forces with at least one or more similarly-sized practices for the purpose of reporting their MIPS data for a performance year. A solo practitioner participating under two TINs may even form a virtual group across both practices.
The virtual group election period for the 2018 reporting period began in October and will close on December 31, 2017; virtual group reporting is not an option for the 2017 reporting period. Unless otherwise indicated in the Quality Payment Program (QPP) Final Rule for 2018, virtual groups will follow the same rules as other group practices participating in MIPS. The following are some key details relative to the formation of a virtual group:
A virtual group must contain TINs comprised of 10 or fewer ECs. TIN size is determined by including in the count those ECs who would otherwise be exempt from MIPS based on low volume, low Medicare dollars or their first year of Medicare participation.
The election to participate in MIPS as a virtual group must occur prior to the start of the applicable performance period and it cannot be changed during the performance period. The two-stage virtual group election process includes:
- Stage 1 (optional) - Determine if solo practitioners and groups are eligible to participate in a virtual group.
- Stage 2 (required) – Virtual group applicants submit the necessary information, including a virtual group agreement, to gain approval to form a virtual group for the upcoming performance period. The approval needs to be renewed each year.
Virtual Group Agreement
A formal, legal written agreement must be established among the solo practitioners and groups that make up a virtual group. It has to include a list of the ECs who bill under the TINs that will be members of the virtual group. The participation requirements and expectations are to be clearly articulated, understood, and agreed upon. The virtual group agreement must be executed on behalf of each TIN by an individual who is authorized to legally bind the party.
Each MIPS-eligible EC who is part of a virtual group will be identified by a unique virtual group participant identifier that is made up of a combination of three identifiers:
- a virtual group identifier established by Medicare,
- the EC’s TIN, and
- the EC’s National Provider Identifier (NPI).
Virtual group reporting poses new requirements and challenges as clinicians will have their performance assessed at the virtual group level across all applicable MIPS performance categories. Here are some reporting considerations:
- The data will be aggregated for each NPI under each TIN participating in a virtual group. Such aggregation across multiple TINs and associated health IT systems may be complex and logistically difficult since each TIN may use IT systems with different ways of collecting and storing data.
- Third party vendors such as qualified data registries, qualified clinical data registries and EHRs will be required to provide methods to collect and aggregate MIPS data from various disparate systems.
- While all of the eligible clinicians in a TIN reporting within the virtual group are required to participate and have their performance scores included in the virtual group score, only “MIPS-eligible” clinicians will receive a MIPS payment adjustment based on the virtual group’s score. A MIPS-eligible clinician is an EC who is not exempt from MIPS based on the exclusion criteria described above.
- MIPS-eligible clinicians who participate in both a virtual group and an Alternative Payment Model (APM) under their TIN will be assessed on their MIPS performance as part of the virtual group and under the APM scoring as part of an APM Entity group, but they will receive their payment adjustment based only on the APM Entity score.
Virtual Group Reporting Pros & Cons
The virtual group concept might initially sound attractive to a small practice. Advantages may include shared responsibility and shared risk, and the availability of resources to support and positively impact performance in the MIPS program that might not otherwise be available to smaller groups or individuals. However, putting the plan into operation could be a bigger challenge than expected and, once the election is made, it will be irrevocable for one performance period. Therefore, EC’s who are contemplating the formation of a virtual group should consider these pros and cons:
- It could be difficult to aggregate data across disparate systems for unified reporting of MIPS measures and activities.
- Control of the virtual group's success will be in the hands of an administrator who may not be part of your own practice.
- There may be logistical challenges in trying to manage groups that are working in different systems, geography, and reporting structures in order to gain compliance. There is a need for clear oversight, trust and commitment among the virtual group’s members in order to succeed.
- Your practice will suffer if another virtual group member doesn't optimize their participation. This would bring down the overall virtual group score that is then attributed to every member of the virtual group.
- Since virtual groups are assessed across all four MIPS performance categories that apply to any of its members, a radiology practice that is exempt from ACI because it is hospital based and/or non-patient facing joins with a practice that is not exempt from ACI, the practice will also absorb the ACI score from the other practice as part of the overall MIPS score across the virtual group. This could be either positive or negative depending on the ACI score. However, it means that each member has even less control over this portion of the MIPS score that will affect its future payments.
- Consider existing contractual obligations with other provider organizations and groups that might impact forming a virtual group.
- Providers may be unaware of their obligation to participate in the virtual group, especially if it has to support many TINs. This is similar to what CMS has found regarding provider participation in APMs. The addition or departure of ECs within a TIN could prove difficult to manage relative to their obligation to participate in the virtual group, which could affect the TIN’s eligibility to continue in the virtual group in subsequent performance years.
- If a solo clinician or group practice is not eligible to participate in MIPS, they are also not eligible to participate in a virtual group.
Radiology practices that are interested in forming a virtual group should download the Virtual Group Toolkit from the CMS Resource Library and follow the directions for making the election. There is a very short window of opportunity to form a virtual group and make the election for the 2018 performance year.
If a virtual group is not the answer, then some considerations surrounding the decision to report as an individual or as a group practice can be found in our article Exempt from MIPS? Think Again About Participating as a Group. Subscribe to this blog for the latest information to help your practice achieve success with MIPS reporting in 2017, 2018, and beyond.
Maria Calamaro is the Executive Advisor and Solution Owner, CMS Quality Payment Program (QPP) Healthcare Administrative Partners. Her areas of expertise include all aspects of CMS Quality Payment Program compliance.