Virtual Groups 2018

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Key Facts About Virtual Groups

ONE YEAR MINIMUM VALIDITY - A virtual group is created for at least one performance year. Once the participants sign the contract to be a part of a virtual group, they cannot change the selection during the performance year. 

PARTICIPATION LIMITED TO ONE VIRTUAL GROUPA solo practitioner or a group can only participate in one virtual group during a performance period, although there is no limit to the number of participants. The virtual group participants are identified at the TIN level. 

BILLING STILL UNDER THE CURRENT TIN - Although a virtual group is recognized as an official collective entity for reporting purposes, it is not a distinct legal entity for billing purposes. Thus, for simplicity of administration, a virtual group will not need to establish a new TIN nor will the VG participants need to reassign their billing rights to a new or a different TIN. 
VIRTUAL GROUP IDENTIFIER - Virtual groups would be identified by a Virtual Group Identifier (VGI). So, each clinician in a virtual group can be uniquely identified using a combination of the 3 identifiers – VGI, TIN, and NPI. 

VGI FOR DATA SUBMISSION - The virtual group will submit the MIPS data to CMS using the Virtual Group Identifier (VGI) for all the member entities. All submission methods available to groups will be available to virtual groups as well. 

AGGREGATE DATA FOR SUBMISSION - Most of the reporting requirements applicable to groups would also be applicable to Virtual Groups, unless otherwise specified. Virtual groups will need to aggregate data for each NPI under each TIN in the virtual group by adding together the numerators and denominators to report the measure ratio at the virtual group level.

Virtual Group Formation Process

Any individual MIPS eligible clinician or a group of 10 or fewer clinicians can form a Virtual Group with at least one other such individual eligible clinician or group.


Each participating individual clinician must exceed the low volume threshold. That is, have greater than $90,000 in Medicare Part B allowed charges for services AND care for more than 200 Medicare Part B patients.


Each participating group has to cross the low volume threshold requirements at the group level. A group may have clinicians (NPIs billing under the group TIN) that do not meet the low volume threshold requirements at individual level. However, there must be at least one MIPS eligible clinician in the group. 

The virtual group election process requires formal written agreements among individual clinicians and groups electing to form a virtual group. CMS has provided guidelines on the election process in the Virtual Group Toolkit available in the QPP resource library.

A virtual group has to appoint a virtual group representative. This person would make the election on behalf of the members of a Virtual Group regarding the formation of a Virtual Group for the applicable performance period. Virtual Groups had to make the election for 2018 performance year by December 31, 2017. 

Virtual Group Reporting Requirements by Category

Number of Measures: Most of the quality measure reporting requirements such as requiring 6 measures including one outcome measure or high priority would also apply to virtual groups. All Cause Hospital Readmission Measure would be included if the virtual group has more than 15 clinicians and meets the case minimum of 200.


Data Aggregation: Just like for group reporting, all the participating TINs in a virtual group will need to report on the same 6 measures. All the participating TINs will need to aggregate the numerators and denominators for each measure chosen to report.


Data Completeness requirement would apply cumulatively across all TINs in a virtual group. If one TIN in a VG falls below the 60% data completeness threshold for measure, the virtual group may still report on that measure as long as it exceeds the data completeness threshold at the VG level.


CMS Web Interface and CAHPS for MIPS: Virtual groups using the CMS Web Interface to submit data for the Quality category, and/or using a CMS approved survey vendor to report the CAHPS for MIPS survey, must meet the data submission requirements on the sample of the Medicare Part B patients specified by CMS. 

PI data for Virtual Groups will be aggregated by combining data from the Certified EHRs of all the participating TINs.


If an individual MIPS eligible clinician meets the criteria to be excluded for a measure, their data can be excluded from the calculation of that particular measure only.


For PI reporting, CMS does NOT require a virtual group to report the data for unique patients only. CMS recognizes that the same patient can be seen by multiple TINs in a virtual group, or different NPIs within a participating TIN of a virtual group, and thus captured in a different EHRs. So, there could be a situation when the same patient is counted multiple times in the denominator and numerator of a measure. 

For the improvement activities performance category, a virtual group would meet the reporting requirements if at least one NPI within the virtual group completes an improvement activity for a minimum of a continuous 90-day period within CY 2018.

No data submission is required for the Cost category. CMS will calculate the score by combining the data for all the clinicians included in a Virtual Group identified by their Virtual Group Identifier (VGI), TIN, and NPI. 

Virtual Group MIPS Score


The MIPS Score for a virtual group will be calculated by combining the scores of all the performance categories using the score calculation rules applicable to groups. All eligible clinicians in a virtual group will receive the same MIPS score based on the combined performance of the entire virtual group.

MIPS Special Considerations

At least 50% of the practice sites within the TINs of a virtual group will need to be recognized or certified as a patient-centered medical home (PCMH) or comparable specialty practice for the virtual group to get full credit in the IA category.

More than 75% of the NPIs billing under a virtual group’s TIN must meet the definition of a non-patient-facing (NPF) MIPS eligible clinician during the NPF determination period.

A virtual group consisting of 15 or fewer eligible clinicians would be eligible for all considerations available to small practices under MIPS.

If more than 75% of NPIs billing under the TINs attributed to a virtual group are situated in the ZIP codes that are designated as rural areas or HPSAs, a virtual group will receive all considerations available to rural or Healthcare Professional Shortage Area (HPSA) practices under all performance categories. 

When TINs Change


In the case of a TIN within a Virtual Group is acquired or merged with another TIN, or is no longer operating as a TIN (in case a group practice closes) during a performance period, such solo practitioner’s or group’s performance data would continue to be attributed to the virtual group that they elected to be a part of. Also, the remaining entities in the virtual group would continue to be part of the virtual group even if only one solo practitioner or group remains.

Payment Adjustments for Virtual Groups

The MIPS score and thus the payment adjustment for a virtual group would be applied to all TIN/NPIs billing under a TIN included in the virtual group during the performance period.


However, this will vary a little bit for clinicians participating in Advanced APMs and MIPS APMs. 

The clinicians who are a part of a virtual group, but are also Qualified Participants (QP status) in an Advanced APM, will have their performance counted as a part of the virtual group, but will NOT receive payment adjustment based on the virtual group MIPS score. These clinicians’ payment adjustment will be covered under the Advanced APM entity.

For the eligible clinicians who are participating in both, a virtual group and a MIPS-APM entity, the MIPS-APM entity’s MIPS score will determine the payment adjustment for those NPIs instead of the virtual group MIPS score. This will hold true even if MIPS-APM's MIPS score is lower than Virtual Group's MIPS score.

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