5 key factors in considering MACRA virtual groups

This article appears in the 5/25/2018 edition of Medical Economics

Changes resulting from CMS’ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have created new opportunities for practices to evolve how they manage payment and reimbursement. One example is that solo practitioners and small practices will be eligible to join a virtual group to report their Quality Payment Program (QPP) measures for the first time.

While not limited on the number of participants, the virtual group is defined as a combination of two or more Taxpayer Identification Numbers (TINs) assigned to one or more solo practitioners, or to one or more groups consisting of 10 or fewer clinicians (including at least one Merit-based Incentive Payments System (MIPS) eligible clinician), or both, that elect to voluntarily form a virtual group for a performance period of a year. There are also no restrictions based on location or specialty.

While a virtual group is not for everyone, clinicians or TINs that join may find it easier to be successful in reporting their QPP metrics, thus earning a potential for greater reimbursement (ranging from 5 percent in 2018, up to 9 percent in 2020).

Practices must weigh several factors before making a decision that could have significant impact on its performance under MIPS.

Data Collection

A key benefit of virtual groups is the ability for clinicians and practices to aggregate data together to report on performance measures. This may help clinicians who are struggling to show significant results by combining data with partners who have stronger results on key performance measures.

However, virtual groups-just like regular groups-must report on all the same measures for the same period. When considering if a virtual group is a good fit, practices should factor in the measures that all participants have available and are applicable to them early in the process to maximize the strength of data available reported for the group: either through registry or EHR.

Partner Reliability

It is important that clinicians and practices join or form virtual groups with other reliable partners. Successful virtual groups have established traits and goals by which they measure potential members before confirming participation. Reliable partners should share similar focuses on providing quality care and accurate reporting.

Once formed, each participant is “locked in” for the entire reporting year, and every NPI or TIN in the virtual group will receive the same score. A provider not taking the steps to be sure he or she is constantly trying to improve may shift measurement scores lower. Virtual group members cannot ask poor performing clinicians and practices to leave the group mid-year. Similarly, individual clinicians or practices cannot exit early to report their own data, which is why it is critical to determine partners who will bolster performance results, rather than hinder them.

Administrative Responsibility

Forming or joining a virtual group may require additional administrative time to a clinician’s or practice’s already busy schedule.
Each virtual group should have a designated representative who can oversee it and handle communications with CMS. Groups may ask clinicians to review a mid-year Quality and Resource Use Report (QRUR) and/or conduct a monthly measurements check to track performance on a consistent basis across all participants.

Additionally, when the group (or specific clinician/practice) is not performing to the standards necessary to maximize reimbursement, if a lead practice has been assigned, they should take the responsibility to provide an action plan to improve. The role of group leader should be determined at the outset of forming the virtual group and clearly defined in written agreements delivered to CMS.

Knowledge Sharing

Through virtual groups, clinicians and practices can work with each other to help increase the overall level of care provided to patients. Virtual groups are a unique opportunity for small, rural area clinicians to share knowledge and best practices with larger practices offering their own perspective.

When making a decision to form or join a virtual group, members should evaluate the value of the knowledge they could gain from shared partnerships.

Outside Support

There are several resources and tools for clinicians and practices interested in joining or creating a virtual group. CMS’ Quality Payment Program Technical Assistance representatives can help figure out if clinicians and practices are eligible to join or form a virtual group before signing any formal written agreements or reallocating resources. CMS has also offered a toolkit, which outlines the process for joining or creating a virtual group, along with resources to get more information.

As clinicians and practices weigh these factors when deciding to join a virtual group, there are outside consulting professionals with expertise that can provide guidance on how to maximize their reimbursement based on updates to MACRA.

Jackie Rogers is the manager of the Quality Reporting Engagement Group at data analysis provider IntrinsiQ Specialty Solutions, a part of AmerisourceBergen.

Virtual groups 101

Q: Who can participate?

• Solo practitioner who is a MIPS eligible clinician, exceeds the low-volume threshold, and is NOT a newly Medicare-enrolled MIPS eligible clinician, a Qualifying APM Participant (QP), or a Partial QP choosing not to participate in MIPS.
• Group that has 10  or fewer clinicians and exceeds the low-volume threshold at the group level.

Q: How many virtual groups
can I join?

• A solo practitioner or group can only participate in 1 virtual group during a performance period.

Q: Are there limits on virtual group size?

• There are no limitson the number of solo practitioners and groups able to form or join a virtual group.

Q: Must all physicians in a practice participate?

• If a group chooses to join a virtual group, all of the clinicians in that group are part of the virtual group.

Source: CMS