Understanding the Reporting Requirement for MIPS Promoting Interoperability
Starting January 1, 2025, ACOs, their participants, providers, and professionals that qualify as MIPS-eligible clinicians, Qualifying Alternative Payment Model (APM) Participants (QPs), or Partial QPs must:
Report the MIPS Promoting Interoperability performance category measures: Reporting must occur at the individual, group, virtual group, or APM Entity level. Essentially, the ACO reports on behalf of its clinicians.
Earn a performance score: ACO participants, providers, or professionals must be meaningful Electronic Health Record (EHR) users, use Certified Electronic Health Record Technology (CEHRT), and report on objectives and measures specified by CMS. Attestation statements must also be completed and submitted to CMS.
For additional information on the MIPS Promoting Interoperability requirements, please visit the 2024 MIPS Promoting Interoperability Measures webpage. Further information can also be found in this MIPS PI Performance Category Frequently Asked Questions document.
Exclusions from the Reporting Requirement
Some ACO participants may be excluded from this reporting requirement if they meet certain criteria, as outlined in 42 CFR part 414, subpart O. Common exclusions include:
- Not exceeding the low volume threshold.
- Being a non-patient facing clinician, hospital-based clinician, ASC-based clinician, or part of a small practice.
- Having a hardship exception granted by CMS for a specific performance year.
It is important to note that QPs or Partial QPs cannot solely use their status as a basis for exclusion. However, if they meet other exclusion criteria, they may be exempt from the reporting requirement.
Steps for Those Believing They Should Be Excluded
Certain reweighting bases require submitting an application to CMS to demonstrate that the criteria for reweighting are met. These include:
- Insufficient internet access.
- Extreme and uncontrollable circumstances that make CEHRT unavailable.
- Lack of control over CEHRT availability in practice locations.
Clinicians who do not have CEHRT should evaluate whether they meet any of the noted exclusions and apply for reweighting, if applicable.
You can apply for the Hardship Exception directly on the QPP website. CMS will notify you by email if your request is approved or denied. Approval will also be added to your eligibility profile in the QPP Participation Status Tool.
Public Reporting Requirement
From performance year 2025 (publicly reported in Fall 2026), ACOs must publicly disclose the number of participants, providers, and professionals that:
- Meet the requirements of 42 CFR § 425.507(a) and are not excluded under 42 CFR § 425.507(b).
- Voluntarily reported and received a MIPS Promoting Interoperability performance category score despite qualifying for an exclusion.
Clinicians who report and earn a MIPS Promoting Interoperability performance category score of zero are considered “scored” for the purposes of the Shared Savings Program requirement for ACOs to report the MIPS Promoting Interoperability performance category and must be included in the count of clinicians that the ACO publicly reports.
Impact on Shared Savings and Program Participation
An ACO's performance in the MIPS Promoting Interoperability category does not directly impact its shared savings or losses. However, ACOs are required to comply with all Shared Savings Program requirements, including this reporting requirement, to be eligible for shared savings.
For further information on how to comply with these requirements, continue to monitor the QPP Resource Library.
Next Steps
ACOs should keep a close eye on upcoming announcements and resources provided by CMS to navigate these requirements effectively. For more information or assistance with MIPS PI reporting, MDinteractive offers support to ensure compliance.
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