MACRA Insights for Clinics and ACOs

Reconcile provider list with QPP - twice

reconcile providersIn our Blueprint for Monthly MACRA, we suggest twice a year to verify your providers against the CMS QPP Website.  That's all there is to it.  You would think that verification to be an unnecessary step.  After all, you know who your providers are, and which TINs are / are not part of an ACO.  The problem is, your records don't always match up with CMS's rules about MACRA.  And the source of truth is the QPP validation web site

CMS updates this stie each year in time for attestation, based on snapshots of claims history.  The most practical snapshot data is as of August 31, which is generally available around November.  

Also, the issue is a bit more tedious for ACOs with "Affiliated Provider" lists, rather than those with "Participation Lists".  In the Affiliated Provider scenario, providers are evaluated individually.  For Participation List ACOs, the evaluation is for the ACO Entity overall.  Still, it makes sense to check.  

The process is a bit tedious, but necessary.  Here's the issue:

  1. If CMS shows a TIN to be excluded from your ACO and you expect the TIN to be part of the ACO, then CMS will not accept CPIA and Quality scores from the ACO.  This will cause the TINs MACRA scores to be zero for Quality and CPIA, greatly reducing the MIPS composite score for the TIN.  In this case, you will need to submit CPIA and CQM for the "mismatched" TIN. 
  2. For Advanced APMs, each provider needs to be verified as Qualifying Participant (QP).  In some cases ... completely out of your control ... providers can be classified by CMS as Partial QPs.  Partial QPs do not receive MIPS credit for ACO membership. However, by submitting MIPS content you can receive significant MIPS positive adjustments. The only way to know about Partial QP status is through the QPP Inquiry Site.  

The process requires that you type in the NPI for each provider, read the status values CMS provides, and flag your providers accordingly.  (We will do this for you for a very modest fee).  

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MACRA Monitor is an subscription-based product from C3 Partners that combines a MACRA database with dedicated Concierge service for ACOs and other complex organizations