Our ACO has a participating group that received a CMS-approved hardship exception for quality reporting due to a ransomware attack. This is the provider:
https://qpp.cms.gov/participation-lookup?npi=1982654554&py=2024
 

Our ACO doesn't have a hardship exception, and we will not request one for quality reporting because not all participating groups were affected. However, our ACO wants to report MIPS CQMs and is concerned that we may not be able to do so because we can't gather quality data from the provider mentioned above.
 
We are not the only ACO facing this scenario. It is our understanding that during the August 2024 Qualified Registry call, it was mentioned that another ACO is facing a similar situation. CMS was asked:
 
"We have an ACO where one of the physicians (a solo practitioner) is out on long-term medical disability, probably throughout 2025. This provider is planning on taking a Medical EUC. The question is whether the medical EUC can apply against her requirement to provide eCQM data to the ACO."

 
CMS replied, as per the official minutes:
 
"The requirement is that the ACOs submit quality data by the APP to report on behalf of the eligible clinicians who bill under the TIN of an ACO participant, so if the clinician has an exemption and is not a MIPS-eligible clinician, I think it would be reasonable to exclude them from the eCQM requirements for the ACO. It would be helpful to submit those details to the Shared Savings Program once a decision has been made or the MIPS EUC."

 
Can our ACO be exempt from requesting quality data from the practice with the approved EUC and still report the MIPS CQM under the APM Performance Pathway?