MSSP Quality Reporting for Providers

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Do you have a questions about MSSP participation, policies, requirements or resources? Contact the ACO operations team.

Collaboration is key to our shared quality performance

The Affordable Care Act paved the way for CMS to begin rewarding quality of care over volume of care, through initiatives such as the Medicare Shared Savings Program (MSSP). Participating ACOs that lower costs while meeting certain quality measures share in the savings achieved.

Learn more about Scripps ACO’s quality reporting requirements, and how we support you in this mutual endeavor.

Overview of MSSP quality reporting

CMS determines whether an ACO qualifies for shared savings based on its performance across 34 quality performance measures. These measures are publicly reported and fall into four domains:

• Patient Experience of Care

• Care Coordination/Patient Safety

• Preventive Health

• At-Risk Population Management

Review the full list of quality performance measures (PDF, 160 KB).

What does the Scripps ACO report on your behalf?

To minimize the burden on you and your staff, the Scripps ACO collects nearly all* clinical quality and patient experience data from your office and reports to CMS on your behalf. This includes CAHPS patient survey data, as well as claims and administrative data. In return, your office needs to ensure precise medical claims coding and record documentation, while making sure your patients receive necessary preventive care

* Federal law requires individual practices to report their own Promoting Interoperability (formerly known as Advancing Care Information) data. ACOs cannot report Promoting Interoperability on behalf of their participating providers. See below for more information.

Quality goals for performance year 2024

For performance year 2024, Scripps ACO is focused on improving the following measures:

Web-Interface (10 measures):
Screening for Future Fall Risk
Diabetes: Hemoglobin A1C Poor Control
Controlling High Blood Pressure
Depression Remission at 12 Months
Breast Cancer Screening
Colorectal Cancer Screening
Influenza Immunization
Tobacco Use Screening & Cessation
Screening for Depression & Follow-up Plan
Statin Therapy
Administrative Claims (2 measures):
Hospital-wide, 30-day, All-cause Unplanned Readmission Rate for MIPS Eligible Clinician Groups
Risk Standardized, All-cause Unplanned Admissions for Multiple Chronic Conditions for ACOs
CAHPS for MIPS (survey)

Reporting Promoting Interoperability

Promoting Interoperability (formerly known as Advancing Care Information) is one of the four performance categories that comprise MACRA’s Merit-Based Incentive Payment System (MIPS). It replaces the Medicare EHR Incentive Program, commonly known as Meaningful Use.

You choose your own weighted measures designed to promote patient engagement and the electronic exchange of information using certified EHR technology.

Due to the unique nature of EHRs, ACOs cannot report Promoting Interoperability on behalf of their participating providers. This means all providers that use electronic health records (EHRs) are required to report their own Promoting Interoperability data. This is crucial for Scripps ACO to maintain its Advanced APM status and continue qualifying for the 5 percent bonus on Medicare Part B professional billings.

Learn more about Promoting Interoperability requirements and scoring, and how participation affects your future Medicare payments.

How to determine whether you are required to report Promoting Interoperability

Figuring out whether you have to report Promoting Interoperability is dependent on your status below.

MIPS eligible clinicians

First, check your MIPS status using this CMS online tool.
If your NPI is identified as included in MIPS, you must report Promoting Interoperability independent of the ACO.
There are different pathways to report Promoting Interoperability and options differ whether you report as an individual or a group practice.
The best source of information on reporting Promoting Interoperability is the CMS' Quality Payment Program website
If you have not already done so, you should contact your technology vendor about reporting Promoting Interoperability. Reporting platforms include Clinical Data Registry (QCDR), Qualified Registry, Electronic Health Record (EHR), administrative claims, attestation, and CMS Web Interface (for group practices only).

Providers who have previously attested Meaningful Use under Medicaid (Medi-Cal)

Providers that have previously attested under Medicaid can continue to report under Medicaid for the duration of their 6-year eligibility.
Providers that began their Medicaid attestation in 2016 can attest under Medicaid through 2021.
As of 2017, no new providers may attest under Medicaid.

Promoting Interoperability (PI) Guidelines

Per updated CMS guidelines, practices with less than 15 providers that have the “small practice” special status will automatically be exempt from PI reporting and will not need to submit a PI hardship exception. You can check to ensure that your practice has the “small practice” special status in QPP or via the NPI lookup feature by following the link below: The Quality Payment Program (cms.gov).

Helpful hints for successful reporting

Remember that Scripps ACO is considered an Advanced APM. Participation in an Advanced APM exempts you from three of the four MIPS reporting requirements — specifically, Quality, Improvement Activities and Cost. However, due to the unique nature of electronic health records, ACOs cannot report Promoting Interoperability data on behalf of their ACO participants. Keep the following in mind:

ACOs report at the participant TIN level, not at the ACO level

ACO participant TINs can aggregate their data by adding together the numerators and denominators from certified electronic health record technology (CEHRT) for each National Provider Identifier (NPI) and rolling them up to one report at the TIN level

MIPS eligible clinicians and ACO participant TINs must meet the following requirements to earn a score for the ACO performance category:

Submit a performance period
Submit a “yes” for each of three health information exchange and prevention of information blocking attestation statements
Fulfill, at a minimum, the base score measures
Promoting Interoperability data must be submitted through the QPP Portal and last reporting period closed March 2018

Scripps ACO requires all participants to report and provide written confirmation of successful submission of Promoting Interoperability regardless of ability to meet base scores, unless the participant provides written proof they have been approved by CMS for a hardship exemption, are a hospital-based practice, or will attest as allowed under Medicaid.

Learn more about, or apply for, a hardship exemption.