Medicare ACO CQM Reporting Option
Accountable Care Organizations (ACOs) participating in the Shared Savings Program are required to report via the APM Performance Pathway (APP) for the purpose of assessing their quality performance for that program. One of the reporting options that ACOs can use for APP quality submission is MIPS CQM collection type.
Links for the 3 quality measures included in the APP measure set (2023 Performance Year) for the CQM collection type are listed below:
​
​
MIPS CQMs are a good option for aggregating data across multiple EHRs as, unlike eCQMs, they have the flexibility to use data from multiple sources, including multiple EHRs, and do not require ONC certification.
MIPS CQM Reporting Option Overview
Implementation Steps
Eligible Population
CQM collection type requires ACOs to report all-payer data. ACOs are reporting on behalf of eligible clinicians from all ACO participants (i.e., TINs). This means that the ACO submission should include aggregated patient data for all matched and deduplicated patients across all ACO participant TINs, for eligible patients as defined in the CQM initial population criteria.
Patient Creation and Deduplication
ACO must be able to capture its full eligible population through multiple EHRs using CEHRT. Aggregation, patient matching, and deduplication across the EHRs is necessary prior to submission of CQM performance to ensure that the ACO meets the measure specification by accounting for its complete patient population. This means a patient may not be reported twice by two different facilities or TINs. Instead, patients must be matched using their demographics to avoid duplication of patients in the data set.
​
Data elements used by Health Endeavors for patient matching and deduplication:
-
Patient ID
-
First Name
-
Last Name
-
Gender
-
Date of Birth
Data Sources
-
Medicare Claims - CPT Category II codes and HCPCS Level II codes
-
QRDA Category I Files - (Single Patient Report) Individual patient-level report that contains data defined in the measure. (Click here for more QRDA information in the eCQI Resource Center)
-
Flat File Imports - Use the Flat File import Template to enter measure responses for import into Health Endeavors. Flat files can be submitted via your SFTP account.
-
Manual Key (auditing only)
Data Completeness
ACO submissions must include 100% of eligible and matched patients across all ACO participants’ (i.e., TINs) patients. The ACO must also meet a data completeness threshold of 70% for 2023 performance years, increasing to 75% for 2024 and 2025 performance years. This means that performance data (i.e., “Met” or “Not Met,” or denominator exceptions) should be present for at least 70% or 75%, as applicable, of the eligible and matched patients that meet the measure's denominator criteria. The measure denominator includes ALL eligible patients. This would include Medicare, Medicaid, Medicare Advantage, commercial and non-insured patients.
Data Submission
Health Endeavors generates a JSON file with final data for ACOs to upload to QPP portal.
CQM Quality Questionnaire
Security Official Training (ACO Leadership)
Your Security Official is the top level in the hierarchy of user roles and permissions. This person will manage user account credentials and maintain facility and provider network configuration in the solution. You may have multiple users with the Security Official role.
​
​
-
My Team is used to set-up new users or update access for current users. ​
​
-
Network Manager is used to configure practices and providers within the ACO.
​
​​​
SFTP Account Setup
The participating provider will need a SFTP account to securely transfer quality measure data.
Please complete our online SFTP form. Once Health Endeavors has completed setup the user will receive a secure email with login and final setup details.
Health Endeavors Tools
​
-
Year-Round Gaps in Care Analysis - Proactive, year-round strategy for identifying, disease and wellness gaps in care significantly improves your quality performance. For most ACOs, the most difficult part of closing care gaps is identifying them. Our solution makes all the difference by automating the process of identifying the incompletes and complete with non-performing responses. Intuitive visuals, with the ability to drill down to patient details. ​
​
​
​
​
​
​
​
​
​
​​
-
Year-Round Performance Scoring - Track year-round performance using CPT II codes, QRDA I and Flat File imports to avoid poor performance surprises at the end of the year. ​
​
​
​
​
​
​
​
​
​
​
ACO will meet the Shared Savings Program quality performance standard if:
​​​​
-
For the 2023 performance year and subsequent performance years, an ACO achieves a quality performance score that is equivalent to or higher than the 40th percentile across all MIPS Quality performance category scores.
​
ACOs that meet the quality performance standard are eligible to share in savings at the maximum sharing rate, and ACOs in 2-sided models share in losses based on their quality score or at a fixed percentage based on track. ACOs that do not meet the quality performance standard are ineligible to share savings and owe the maximum amount of shared losses, if applicable.
EHR Feedback Reports are created to give you and overview of what data we are receiving in your QRDA or Flat files. Each report shows a summary of the measures and answer types we were able to find in your files.
