What Your Practice Should Consider When Forming or Joining a Virtual Group for QPP

CMS created a Virtual Group option for healthcare providers to report their Quality Payment Program (QPP) measures from 2018. The group is defined as a combination of 2 or more Taxpayer Identification Numbers (TINs) assigned to 1 or more solo practitioners, or to 1 or more groups consisting of 10 or fewer clinicians (including at least 1 clinician eligible for the Merit-based Incentive Payment [MIPS] program), or both, that elect to form a virtual group for a performance period for a year.

This new “group reporting” will allow multiple/different TINs and CMS will assign a new, unique identifier. For example, 5 TINs with 9 clinicians each could join and form a virtual group of 45 total clinicians.

While the program is entirely voluntary, practices must be a solo practitioner or in a group that has 10 or fewer clinicians. There are no limits as to how many solo practitioners or groups can join, but in the case of groups, all clinicians in that specific TIN are included in the reporting. Therefore, practices cannot pick and choose which physicians are represented in the reporting. This is an important consideration as one physician’s performance could impact reporting for the rest of the group. There are also no restrictions based on location or specialty.

Virtual groups have been formed for the 2018 reporting year, but CMS will open the application process again for the 2019 reporting year, typically around mid-September. There are several steps to forming a virtual group, including an approval process with CMS, designating a Group Representative and executing formal written agreements between all parties. CMS has guidelines available about what must be included in the written agreements for virtual groups in their toolkit.

The benefits of joining a virtual group:

• While a virtual group is not for everyone, clinicians or TINs that join may find it easier to be successful in reporting under the QPP, thus earning a potential for greater reimbursement. The increases can run from a positive upward adjustment of 5% percent in 2018 to up to a 9% positive upward adjustment in the 2020 reporting year, as payment adjustments are applied 2 years after the reporting year.
• For practices or physicians in rural communities, the virtual group offers a way to potentially reduce the burden of being included in the payment program.
• Similar to regular groups, clinicians in virtual groups will have their data combined for scoring purposes. This may help clinicians who struggle with measures do better overall as their performance is rolled into the group.
• Virtual groups can also be non-patient facing, and will be scored in the same way as other MIPS-eligible clinicians.
• All policies that apply to regular groups also apply to virtual groups, with a few modifications—for instance, the small practice, non-patient facing, and Health Professional Shortage Area (HPSA) policies apply if the virtual group meets the criteria. It is not based on the individual practices within the group, but the group as a whole.

The challenges with joining a virtual group:

• Practices need to consider the other clinicians or providers when creating a new virtual group. All members should be focused on quality care and accurate reporting, as every clinician in the group will have his data aggregated into the group’s reporting. A provider not taking the steps that ensure they are constantly trying to improve may lower the measures score.
• Once a physician or practice has entered the virtual group, they are “in” for the entire reporting year. There is no exiting early to report on your own data, and no asking members to leave for poor performance. Clinicians are locked in and every National Provider Identifier (NPI) or TIN in the virtual group will receive the same score.
• There may also be some extra administrative work on a specific practice if they have agreed to be the designated representative and oversee the virtual group. The clinician or practice will be responsible for communications with CMS.
• In addition, it’s possible that the group as a whole has asked clinicians to review mid-year Quality and Resource Use Reports (QRURs) or do a monthly measures check to see where performance stands. The lead practice may take on the responsibility to help a faltering practice with improvement processes. Roles and responsibilities should be clearly defined in your formal written agreements.
• Virtual groups, just like regular groups, must report on all the same measures, for the same time period. This means that measures should be considered and chosen early on. When forming the virtual group, consideration must be taken for measures that are available, either through registry or electronic health records (EHRs), and applicable to all potential members.
• Data must be aggregated for the group for each performance year prior to submission, so practices will not be submitting in separate submissions and have that data aggregated by CMS.
• It is likely, especially with groups on different EHRs, that virtual groups will be logistically limited to Registry or Quality Clinical Data Registry (QCDR) reporting. This should be a consideration, including with respects to fees for reporting, prior to joining a virtual group.

CMS created options for joining virtual groups—by either creating one on your own, or requesting eligibility to join a virtual group through CMS. If a practice or clinician decides to join or create a virtual group, they must contact their CMS Technical Assistance Representative to determine eligibility, prior to any formal agreements being drafted.

In any event, eligible clinicians need to decide the best option for themselves. CMS has offered a toolkit which outlines the process for joining or creating a virtual group, along with resources to get more information. Additionally, it is recommended that if your practice requires any assistance or advice as to whether to join a virtual group, a seasoned consulting professional with a robust level of expertise should be sought.