Medicare ACO - APM Entity Reporting Option 

  • 3 MIPS CQM/eCQM Quality Measures

    • Quality ID #1 (NQF 0059): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    • Quality ID #236 (NQF 0018): Controlling High Blood Pressure

    • Quality ID #134 (NQF 0418): Screening for Depression and Follow-Up Plan​

  • 2 Claims-Based Measures

    • Hospital-Wide, 30-day All-Cause Unplanned Readmission (HWR)​

    • Risk Standardized:  All-Cause Unplanned Admissions for Multiple Chronic Conditions (MCC)

  • 1 CAHPS for MIPS

  • 70% of Eligible Patients (Medicare and Non-Medicare)

Table of Contents


Medicare ACO QPP APM Entity Onboarding - Table of Contents

Step One:  ACO leadership complete and submit Medicare ACO quality reporting options.


Step Two:  New Client Company Setup

Audience:  ACO Management Team

Step Three:  Learn the quality measures and patient selection

Audience:  ACO Management Team and Participating Clinics

Step Four:  Select clinic data imports

Audience:  ACO Management Team

Step Five:  Complete solution training

Audience:  ACO Management Team and Participating Clinics

Step Six:  Planning for 70% of patients from all payers

Audience:  ACO Management Team and Participating Clinics

Step Seven:  Documentation Audit

Audience:  ACO Management Team and Participating Clinics


Step 2: New Client Company Setup 

  • Register your company information such as primary contact person, address, phone, email and Security Official(s).  Your Security Official is the top level in the hierarchy of user roles and permissions. This person will manage user account credentials, data import priorities and maintain facility and provider network configuration in the solution.   You may have multiple users with Security Official role.

  • Schedule one session for all security officials for Network Manager,  Quality Import Chart and My Team training.  The training will take one hour.   

    • My team is used to setup users.

    • Quality Import Chart is used to configure data priorities such as EHR and claims. Review the handout and video and select your priorities in the solution.

    • Network Manager is used to configure:

      • Assignment for patients on Commercial Membership Rosters.

      • Assignment for patients on ACO Attribution List - HALR (Historical Assignment) and QALR (Quarterly Assignment List Report) files.

      • Divisions, Facilities, Locations, Providers

Step 3: Learn the Measures and Patient Selection 


Step 4: Select Data Import Types for ALL Facilities


Year-Round Submissions.


This step will require each participating provider to setup an appointment to discuss and select the year-round quality measure data sources.  The data sources available for selection include:

  • ​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.

  • SMART on FHIR (Cerner, Epic or Allscripts only)

  • Manual Key

End-of-Year Submission

  • QRDA Category III (Calculated Report) - Aggregate quality report with a result for a given population and period of time for ACO submission and separate TIN submission (optional).

The participating provider will need a SFTP account securely  transfer quality measure data. 

During the appointment, we will ask for completion of the SFTP Connection Worksheet.

Step 5: Complete Gap Analysis, Scoring and Scorecard Training


Complete training:  Updated Video Modules COMING SOON

  • Year-Round Gaps in Care Analysis - Proactive, year-round strategy for identifying, disease and wellness gaps in care significantly improves your quality performance

  • Year-Round Performance Scoring - Track year-round performance using CPT II codes, QRDA I and SMART on FHIR to avoid poor performance surprises at the end of the year.

  • On-Demand Provider Scorecard - Quickly and consistently deliver electronic provider scorecards on performance and progress to help your team meet metric goals

ACO will meet the Shared Savings Program quality performance standard if: 

  • For performance years 2021 and 2022, the ACO achieves a quality performance score that is equivalent to or higher than the 30th percentile across all MIPS Quality performance category scores; and


  • For the 2023 performance year and subsequent performance years, and 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. 


Step 6: Planning for 70% of all Payers

One change for Medicare ACOs that is mandatory for 2022, is the requirement to report the quality measures for 70% of patients with a qualifying encounter from all payers.  This would include Medicaid, Medicare Advantage, and commercial plans.   Keep in mind that many patients will not qualify for the 3 APM Entity measures as not in the age range or have an applicable diagnosis.

The easiest way to report at the end of the year is to remit the QRDA III file from your EHR as that file will include all patients, regardless of payer. We suggest you take some time and review the Data Sources Flow Chart link below and we will meet with you April 2021 to discuss commercial patient rosters and commercial claims data. 

Step 7:  Documentation Audit


As a qualified registry we are required to work with Medicare on a data validation plan each year when we renew our registry and at the close of the year.  Our Medicare data validation plan requires us to conduct an annual audit of each clinic participating in the registry.


This involves our team submitting a random sample of patients (securely) to the clinic to be audited by the client in the EHR to verify measure documentation.   After the audit of the EHR documentation, we then meet with the clinic to review the findings.