Letter to CMMI Regarding Qualifying Threshold Amount Discrepancies

June 8, 2020

Brad Smith
Deputy Administrator & Director
Center for Medicare & Medicaid Innovation
U.S. Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201

Dear Deputy Administrator Smith:

America’s Physician Groups (APG) applauds the Centers for Medicare and Medicaid Services (CMS) for its years long efforts in promoting value-based care and the transition from volume to value. Recently, APG member organizations have been notified that their accountable care organization (ACO) advanced payment model (APM) entities if they have met the qualifying threshold amounts for qualifying participants (QP in order to receive the 5% percent bonus). After investigation we have identified some discrepancies in the data attributed to some of our member organizations that may have had an impact on their threshold amounts. We would ask that CMS appropriately address these discrepancies to ensure that they have no negative effect on threshold scores and ultimately the provider’s qualification for the 5% bonus.

About America’s Physician Groups
APG is a national professional association representing over 300 physician groups that employee or contract with approximately 195,000 physicians that provide care for nearly 45 million patients. Our tagline, “Taking Responsibility for America’s Health,” represents our members’ vision to move away from the antiquated fee-for-service (FFS) reimbursement system where clinicians are paid “per click” for each service rendered rather than on the outcomes of the care provided. Our preferred model of accountable, risk based, and coordinated care avoids incentives for the high utilization associated with FFS reimbursement. APG member organizations are also working diligently to rise to the challenge presented by the COVID-19 pandemic and we appreciate the flexibilities and waivers CMS has afforded us during this time of crisis.

Summary of Recommendations

• Entities must be granted access to the final data sets used for threshold calculations in order to better understand, reconcile, and validate the information used to make determinations

• An appeal process should be established so that entities are able to contest the ruling of their qualifying participant status and be eligible for a re-review

Many of our member organizations that are currently participating as ACOs in alternative payment models have discovered that data downloaded from the QPP portal contains a multitude of errors including inaccurate inclusion of potential and preferred providers. By including preferred providers in calculations of threshold scores, participating entities are unable to account for potential impact to their scores resulting in an inability to properly prepare for achieving qualifying participant status. CMS must work to guarantee that providers included the data utilized to calculate threshold scores are the providers that are actually participating within an APM.

In light of the discovery that an MSSP participant was mistakenly designated as a participant with another APM under the Maryland Total Cost of Care Model, both CMS and the Maryland Total Cost of Care team confirmed that it was an error that would be corrected. However, the correction would only be made on the rerun of the 4th snapshot only and thus would not amend any potential influence on threshold scores
in the first 3 snapshots. Limiting the correction of this mistake to one portion of the  entity’s snapshots instead of the entirety has an unfair negative effect on their ability to meet the necessary threshold score as a qualifying participant. In general, it has been found that some eligible providers are being designated as participating providers within multiple Medicare Shared Savings Programs (MSSP) under the same tax
identification number (TIN). This issue extends to several TINs in violation of CMS’ model overlap rules. It is important that CMS ensures an accurate accounting of participating providers within participant TINs so that all entities have a fair and equitable chance at achieving qualified participant status. CMS must allow entities access to the final data sets used for threshold calculations in order to better understand, reconcile, and validate the information used to make eligibility determinations.

Finally, we have found that many APM entities lack access to the complete data necessary to make accurate calculations of threshold scores, or make the necessary changes in order to meet future thresholds, due to existing limitations with the data sharing process. These limitations prevent APMs from being able to make the necessary adjustments in real-time that would allow them successfully participate as qualifying participants. In light of all of the above identified issues, we recommend that CMS establish an appeal process that will allow entities to contest the determination of their qualifying participant status and being a process of re-reviewing their eligibility.

Thank you for your attention to our concerns. We look forward to continuing to work with you throughout this process. Please feel free to contact Valinda Rutledge, Senior Vice President, Federal Affairs, (vrutledge@apg.org) if you have any questions or if America’s Physician Groups can provide any assistance as you consider these issues.


Donald H. Crane
President and CEO
America’s Physician Groups


Please click here to download a copy of the letter.