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How to set-up a QPP compliant reporting mechanism

Posted on: 12.14.17

Are you overwhelmed thinking about creating QPP compliant reporting? Well, you’ll be relieved to learn it’s not very different from the way in which you previously reported your data, especially under the Quality category. CMS does require different reporting thresholds and specific information for certain reporting mechanisms, however. You’ll have to capture additional information that was not included, so you’re not totally off the hook.

Quality measures

Under QPP, quality measures account for 60% of the MIPS composite score, so it’s critical to choose and report on the measures that will best fit your practice. Review the quality measures outlined in the MACRA final rule. Select up to six measures and one outcome measure from the approved list of either the individual quality measures for MIPS 2017 reporting or the MIPS 2017 specialty reporting. In doing so, consider what you’ve previously reported for PQRS and the feedback you’ve received. Be careful though that you don’t continue to choose ease of data collection over the value of the score since the importance of the outcome now has a significant impact on your reimbursements. Compare your historical numbers against the benchmarks to gain insight into whether you should keep or replace the measurements in your 2017 reporting.

When it comes to improving performance on a specific measure, you’ll also need to consider the extent to which your existing workflow will need to be improved and the feasibility of implementing and maintaining those modifications. Remember, reporting is required, but your performance in each category is what determines your score. Maximizing your performance and your score is key.

As a rule, all quality measures must be reported in the same manner, so whether that’s Part B claims, EHR, registry, etc., the chosen reporting mechanism will also impact which measures are able to be included.

Advancing care information

The MIPS advancing care information (ACI) category replaces the meaningful use program and accounts for 25% of your MIPS composite score. To meet the requirements of this category, you’ll need an Electronic Health Record (EHR) vendor. If you’re not currently using an EHR product and service, you’ll need to purchase and implement one, but be sure the product you choose is certified. An EHR is certified when it has met the technological capability, functionality, and security requirements required by the Secretary of Health and Human Services and has also received certification by the Office of the National Coordinator (ONC) and CNS. If you already have an EHR vendor, be sure to inquire about their MIPS readiness plan and how they can assist you in your meeting your MIPS objectives.

Four Advancing Care Information measures are required for 2017, and 5 measures each year following. There are 9 additional measures in the Performance Score that are optional and available to earn extra points. With your EHR vendor, it’s critical to discuss the issues of data ownership, commitment to future certification requirements, and public health reporting options. You’ll also need to conduct a security risk analysis each year to ensure the privacy and security of your patients’ health information.

Improvement activities

The Improvement Activities category of MIPS accounts for 15% of the MIPS composite score. It evaluates the degree in which you participate in activities that work to improve your clinical practice. You’ll need to choose from the list of activities in this category and demonstrate your performance in 4 of them over a period of 90 days.

Attesting to improvement activities can be done through your choice of the CMS Quality Payment Program website, a qualified registry or qualified clinical data registry, or your EHR system. This is the simplest form of reporting since you only need to confirm that the activity was completed. You can choose the activities that are most meaningful to your practice since there are no subcategory reporting requirements.

You’ll need to click “Yes” to each activity that meets the 90-day requirement on the CMS Quality Payment Program website or work with your EHR vendor to determine the best way to submit the confirmation of completed activities through a qualified registry, qualified clinical data registry, or EHR.

Regardless of the submission method, the CMS document policy requires you to keep any supporting documentation for 6 years.

Auditing your submitted information

CMS will selectively conduct annual audits to validate data submitted under MIPS, so you should always be prepared for a potential audit. Be sure you’re using EHR templates for your documentation and that they include the required support for each measure. It’s also helpful to keep a record of the patients on whom you report for each measure and the specific time period so they can be easily identified in the case of an audit.

The basics of the Quality Payment Program (QPP) and what it means for your practice

Posted on: 11.09.17

In an effort to move away from fee-for-service payments and put more emphasis on quality of care, CMS unveiled the new Quality Payment Program under The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The program’s goal is to improve reporting and ultimately change the way clinicians are paid for their services under Medicare. Quantity can no longer be the driver when quality is the sacrifice to getting there. The new QPP is a major step in improving care across the entire healthcare system.

Back to basics

Participation in the QPP program is gained through the physician’s choice of one of two pathways: the Merit based Incentive Payment Program (MIPS), which combines the previous PQRS the Value-based Modifier and Meaningful Use programs or the Alternative Payment Model (APM). The path they choose will depend upon their practice size, specialty, location, or patient population. Eligible participants are those clinicians who report Medicare services in the amount of $30,000 and care for 100+ Medicare patients per year.

What does that mean for my practice?

The new program brings a list of tasks for those who prepare to participate. If you’ve determined that your practice is MIPS-eligible, through either a letter received from CMS or by using the CMS MIPS eligibility determination look up tool, you’ll need to implement an action plan that will allow you to submit some or all of your data during the first quarter of 2018—or be subject to a 4% penalty.

Between now and then, you’ll need to review the available performance categories and components, “pick your pace” for participation, identify and implement your reporting mechanism, and finally, review and submit your data before the deadline.

Performance categories: Quality, Advancing Care Information (ACI), and Improvement Activities (IA) are the categories available to describe performance for the 2017 year. It’s important to consider which components will help you successfully reach your 2017 reporting requirements.

Under the Quality category, you’ll need to choose six measures on which to report. You’ll need to have completed 4 activities over a period of 90 days under the Improvement Activities category, and the Advancing Care Information category will require at least five qualifying measures with the option to submit others for additional credit.

“Pick your pace”: During the transition year, you have the ability to “pick your pace,” which allows you to choose whether all, a portion, or none of your data will be reported for 2017. You could have started reporting as early as January 1 or as late as October 2, 2017. If you submit a full year of data for 2017, you may earn a positive payment adjustment. If you submit at least 90 days of data, you may earn a neutral or positive payment adjustment. Even if you submit the minimum amount of data to Medicare, you may still be able to earn a positive payment adjustment. Any payment adjustment is determined by the data submitted, not the length of time it encompasses.

Reporting mechanisms: Will you report as an individual or as a group? Which reporting mechanism will best fit the needs of your practice? Are you working with an EHR vendor? If you’re currently using a vendor, ensure their product will be upgraded to meet your MIPS reporting needs.

What if I miss the October 2nd deadline?

The deadline to begin gathering data to send to Medicare is October 2, 2017. If you’re unable to send the minimum 90-day reporting, your practice will be subject to a 4% penalty.

If your office is MIPS-eligible, it’s critical for you to educate your office staff about MIPS, how performance will be evaluated, and how it will affect your Medicare payments beginning in 2019. Completing your preparation before the October 2nd deadline must be a group effort. When everyone is up-to-date on legislation, is aware of the progress, and understands the repercussions, the process will run much more smoothly.

Four ways MACRA can hurt your practice

Posted on: 10.26.17

MACRA requirements have many physicians throwing up their hands in frustration. Extensive changes to their reporting and practice structure are creating a scramble to both understand the rules and create systems to comply.

While some are hoping for a legislative fix, the program is in place and here to stay. Ignoring MACRA will only cost your practice time, money, frustration, and will delay the opportunities for benefits that the program allows. Many practices are unsure of exactly what the rule will mean for them so we’ve compiled four different ways that MACRA can hurt your practice.

1. Possibility of lower reimbursements

The incentive-based MACRA program was designed to cut both ways. Practices that comply and show positive results with patient care are eligible for increases in Medicare reimbursements. But, practices which are less careful with compliance, or cannot show positive results with their choice of direction for patient care, will be penalized with a reduction in Medicare reimbursement. Beginning in 2019, your Medicare reimbursement rates will be directly affected by your MACRA compliance and penalties can be as high as 7%.

2. More paperwork and administrative staff

The core of MACRA involves collecting and reporting patient data to CMS. Growing pains will certainly be part of the process as practices adapt to meet the requirements. New systems, new hires, and a new outlook will be needed to create a workflow that includes the digital vision of MACRA. The law has been termed by some as “death by bureaucratic stranglehold” and practices will need to hire new staff dedicated to addressing the paperwork and data collection, or reorganize current staff to meet the requirements.

3. Capital investments

Encouraging practices to embrace new technology is central to MACRA. The collection of data required by the law will require the purchase and introduction of enhanced software systems such as EHR software, Clinical Decision Support software, and online PACS.

4. Public scoring

Another aspect of MACRA will be a scoring system that will be made public. This component will become increasingly significant as the data is aggregated via web services. Non-compliance or low scores could cost referrals and future patients.

The bottom line

Though many practices will take a wait-and-see attitude before adjusting their systems, it will be those who learn, understand and take action with their practices that will be ahead of the game.

Four ways MACRA can help your practice

Posted on: 09.28.17

For the foreseeable future, MACRA requirements are in place and here to stay. While many are scrambling to understand the new rules and perhaps complaining about the changes it brings, one simple fact is clear: ignoring MACRA will directly cost you money.

Conversely though, the program also offers unprecedented opportunities for medical practices. Embrace it, and the benefits the program brings, are yours sooner than later. Although complicated, MACRA does indeed provide means for good news to medical practices. Here are four ways MACRA can help your practice…

1. Elimination of Sustainable Growth Formula

MACRA replaces the payment formula set forth by the Sustainable Growth Rate (SGR) which had been spiraling out of control and considered a dysfunctional mess for physicians. MACRA prevents previously scheduled payment cuts to Medicare recipients, thus the doctors that treat them. With MACRA, the SGR is gone, and the yearly uncertainty surrounding the fix is gone..

2. Potential for greater reimbursement

MACRA’s clearest benefit for physicians is a financial incentive for compliance with the rules. The increase in reimbursement can be up to 5%, and additional modifier incentives are available for the results-driven accountability of patient care. On $500,000 of revenue, that’s an extra $35,000 for the same amount of patient care.

3. Improved patient outcomes

MACRA’s structure is designed to overhaul the entire medical community. The program’s design moves payment from a service-based reimbursement to a “value-based” health care system that rewards outcomes. The requirements within MACRA are expected to result in the more thoughtful selection of tests, more streamlined diagnoses, and ultimately healthier patients.

4. Streamlined systems

While daunting in its infancy, the reporting requirements of MACRA will be addressed through new vendors and technology. Intimidating changes will transition into new systems that offer continuity between providers as well as great strides in the health information exchange (HIE) — a key goal for the program. While it’s rare for a practice to proactively make such a rapid change, modern technology and new reporting tools can bring significant benefit and efficiency to your practice.

Understanding your QRUR

Posted on: 08.22.17

CMS’ Quality and Resource Utilization Report can be used to gauge performance in the same way as the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM) programs.

What is the QRUR?

The new Quality and Resource Utilization Report (QRUR) is a report that was developed by CMS to provide cost performance and quality of care feedback to participants and to provide comparisons against national peer benchmarks.

Why is the QRUR important?

In assessing a practice’s individual performance as it relates to cost and quality of care, it can help providers identify opportunities for improvement and help maximize current and future payments.

The individual taxpayer identification number (TIN) performance measures captured in the QRUR are also used in the calculation of the Value Based Payment Modifier, the positive, negative or neutral payment adjustments that are calculated annually. The report will show how your Medicare FFS payments will be adjusted based on your demonstrated cost and quality performance compared to your peers.

When are QRUR’s available?

QRURs are generated mid-year and year-end. The purpose of the mid-year QRUR is to allow participants the opportunity to assess their performance and make any necessary adjustments before year-end. The mid-year QRUR includes only CMS-calculated measures from Medicare claims and does not include any Quality data reported as part of the Physician Quality Reporting System. It is for informational purposes only and will not affect any Medicare FFS payments.

The year-end QRUR, which is available in the fall of the following year, is a comprehensive summary report for the entire reporting period, January through December. It includes the PQRS quality measures as well as the cost performance and quality of care measures calculated by CMS. This information will be used to calculate the positive, negative or neutral adjustment to Medicare FFS payments under the Value-Based Payment Modifier.

How to access your QRUR

QRURs are available for each enrolled TIN. However, they are not automatically delivered to each provider. In order to access your QRUR, one person from your office will need to obtain an Enterprise Identity Management System (EIDM) account with a Security Official role. Once your account is established, visit the CMS Enterprise Portal. CMS also provides a quick reference guide that will help walk you through the process.

MACRA implementation timeline and key dates you should be aware of

Posted on: 08.10.17

While 2017 and 2018 are transition years for the Medicare Access and CHIP Reauthorization Act (MACRA), there are several key dates of which to be aware. Adequately planning and preparation will offer you the best chance of success in 2019 when benchmarks and reporting begin to substantially affect your reimbursements. Here’s a timeline of important dates to keep in mind:


  • January 1: Start of the 2017 performance year
  • March 31: 1st snapshot of APM participation list for 2017 performance period
  • June 20: Last day to register to participate in MIPS for the 2017 performance period
  • June 30: 2nd snapshot of APM participation list for 2017 performance period
  • August 31: 3rd snapshot of APM participation list for 2017 performance period
  • October 2: Last day to begin collecting MIPS data for any group or individual clinicians seeking to report a minimum of one continuous 90-day period for 2017
  • November 1: Performance benchmarks for the 2018 MIPS performance period announced
  • Late 2017: Clinicians and groups meeting the 2018 performance year low-volume threshold MIPS exception or non-patient facing status are notified based on their Medicare services provided during the 2017 calendar year


  • January 1: Start of 2018 performance year
  • January 2 – March 31: Window for submitting 2017 MIPS and Advanced APM data for 2017
  • Spring: Final 2018 payment adjustments go into effect for all clinicians and groups under the final year of PQRS, EHR Incentive Program and Value-Based Payment Modifier based on 2016 performance
  • Estimated July 31: CMS provides 2017 MIPS performance period feedback and 2019 payment adjustment determinations to groups and individual clinicians
  • July 31 – September 30: Window for requesting a targeted review of a 2019 MIPS payment adjustment determination based on 2017 performance feedback


  • Spring: First MIPS payment adjustments of +/- 4% based on 2017 performance begin to be factored into Medicare Part B payments. Advanced APM Qualifying Participants will receive a lump sum payment equal to 5% of the estimated aggregate payment amounts for Medicare Part B covered professional services provided during the 2018 calendar year.

Healthcare QuickLinks: MPI imaging in women, proposed 2018 MACRA Proposed Rule, and more

Posted on: 08.03.17

Healthcare is ever changing, so it’s important to stay up to date on advancements and issues that may impact the development, operation, maintenance, and growth of your services. Here are some important developments:

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Continue reading…

10 things to know about CMS’ new 2018 MACRA proposed rule

CMS released its proposed 2018 regulatory updates for MACRA’s Quality Payment Program. Officially titled, “CY 2018 Updates to the Quality Payment Program,” the rule includes several key policy updates that would impact providers’ participation in MACRA starting in 2018. And at 1,058 pages in length, for those who have other items atop their summer reading list, here are 10 Things to Know about CMS’ New 2018 MACRA Proposed Rule. Continue reading…

Human enzyme may be key to unraveling Alzheimer’s disease

Neurodegenerative diseases already affect millions of people in the United States and by some estimates, in 30 years, there will be 12 million people in the U.S. living with a neurodegenerative condition. These diseases include Alzheimer’s, Parkinson’s, Lou Gehrig’s disease and Huntington’s disease. Protein aggregates are the hallmark of a number of these neurodegenerative diseases. New research, published in the journal PLOS Biology, examines a human enzyme that unravels these disruptive plaques. Continue reading…

Study: Physicians miss early signs of heart disease more often than they should

New research points to evidence that general practitioners could be putting patients at a higher risk for severe cardiovascular outcomes by missing initial signs and symptoms for heart disease that could lead to an early diagnosis. The research, published online in The Joint Commission Journal on Quality and Patient Safety, was conducted by CRICO Strategies, a research and analysis organization, and the Doctors Company, a medical malpractice insurance company. The study included more than 250 closed medical malpractice cases in which patients alleged that a general medical practitioner in an outpatient setting failed to identify cardiovascular disease. Continue reading…

Novel PET tracer detects small blood clots

Blood clots in veins and arteries can lead to heart attack, stroke, and pulmonary embolism, which are major causes of mortality. In the featured article of The Journal of Nuclear Medicine‘s (JNM) July 2017 issue, German researchers show that targeting GPIIb/IIIa receptors, the key receptor involved in platelet clumping, with a fluorine-18 (18F) labeled ligand is a promising approach for diagnostic imaging. Current imaging modalities rely on structural characteristics, such as vascular flow impairment, and do not address the critical molecular components. Continue reading…

Hospital impact—Providers beware: Performance under MIPS can influence overall patient volume

The Merit-based Incentive Payment System (MIPS) is an attempt by the federal government to characterize in a single score the value of a provider’s care relative to other providers. Though the program is not without its challenges and limitations, it does begin to give consumers some information they need to make informed choices and benefit from competition. The healthcare industry is in the position of having this transparency imposed upon it via federal action because the providers themselves have been slow to tackle true accountability. Continue reading…

What are the PQRS requirements?

Posted on: 06.29.17

The Medicare Access and Chip Reauthorization Act of 2015 (MACRA) repealed the flawed Sustainable Growth Rate (SGR) reimbursement formula and replaced it with the new value-based reimbursement system called the Quality Payment Program (QPP). The program includes the choice between two major tracks: The Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

QPP and its effect on PQRS

The Quality Payment Program essentially adopted the quality measures and reporting methods from the Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs. Although there are some changes to the PQRS reporting methods, the quality reporting methods are effectively the same. The new system defines four different categories of performance, which contribute to the annual MIPS final score that ultimately determines the negative or positive adjustment to the physician’s payment.

The revised reporting structure is touted to be less burdensome than the previous PQRS. The number of measures was reduced from nine to six, and none of those measures are required to be chosen from the National Quality Strategy domain. The performance period was also shortened by more than nine months.

Do you meet the eligibility requirements?

MIPS will grow to include most healthcare professionals who bill for Medicare Part B, but depending upon the performance year, you’ll gradually be drawn into the reporting group. Initially, it’ll expand it’s coverage over the first few years:

  • 2017 and 2018: Includes physicians, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists.
  • 2019 and beyond: It will also include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals.

Are you exempt from the eligibility requirements?

There are some providers who may meet the eligibility requirements, but for one reason or another, are exempt from MIPS. For the 2017 performance year, there are three exemptions:

  • Clinicians who are in their first year of Medicare Part B participation
  • Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for up to 100 Part B patients in one year
  • Clinicians in entities sufficiently participating in an Advanced APM

What are the data submission requirements?

One of the objectives of the Quality Payment Program is to consolidate all of the MIPS performance data submissions into one single efficient transmission. In order to support this effort, MIPS is expanding its current PQRS quality reporting methods, such as registry, EHR, and QCDR, to allow for reporting measures across the MIPS categories of Quality, Advanced Care Information, and Improvement Activities.

What is MIPS?

Posted on: 06.15.17

The Merit-Based Incentive Payment System (MIPS) is the highly anticipated replacement for the flawed Sustainable Growth Rate (SGR) program. Slated to begin in 2019, the new payment system will negatively and positively adjust individual payments based on provider performance and ultimately demand the highest quality of patient care from healthcare professionals.

How does your performance compare?

A mean performance score of all MIPS-eligible professionals during a given time period will establish a benchmark score. Each participating physician will then receive a combined performance score of 0-100, based on their individual performance in each of the four categories:

  • Quality (30 points): PQRS, EHR MU, and Qualified Clinical Data Registries (QCDRs)
  • Resource use (30 points): VBM and episodes of care
  • EHR Meaningful Use (25 points): EHR Meaningful Use
  • Clinical practice improvement (15 points): Credit for clinical practice improvement activities such as MOC Part IV and QCDRs.

By comparison, scores that fall above the benchmark will receive a positive payment adjustment and those that fall below the benchmark will receive a negative adjustment.

The scores and their corresponding adjustments will remain in effect for one year and will not necessarily impact next year’s adjustment. On a positive note, however, credit can be given for improvement from year to year as well as for achievement.

Negative and positive adjustments

Under the MIPS program, positive payment adjustments can be up to 4% in 2019 and grow to a maximum of 9% in 2022 and beyond. Depending upon the number of high versus low performing professionals, these percentages can be adjusted to keep the budget balanced. However, even if all physicians meet the MIPS threshold, there is a special Additional Incentive Payment per year that ensures funds for positive updates.

The maximum negative adjustment will be applied for scores that fall between 0 and ¼ of the threshold and professionals with scores closer to the threshold will receive proportionally smaller negative payment adjustments. Negative adjustments will be capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond. Professionals whose performance score is equal to the threshold will not receive any adjustment.

MIPS will apply to most all professionals with the exception of providers in rural areas, certain specialties and those participating in Advance Payment Models (APMs).

What is MACRA?

Posted on: 05.25.17

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law on April 16, 2015. It was designed to incorporate the approximately 20 “doc fixes” to the 1997 Balanced Budget Act’s flawed Sustainable Growth Rate (SGR) payment system.

Repealing the SGR provision

Most notably, MACRA repealed the controversial SGR payment system, a fee for service reimbursement model that would have significantly reduced physician salaries, and replaced it with a two-track payment system, the Quality Payment Program (QPP), that will be tied to performance. It will significantly impact the way physicians and healthcare providers are paid under Part B of the Medicare Program.

The delivery of quality and effective care will be major components when it comes to determining reimbursement rates for physicians. More emphasis will be placed on value, as opposed to volume under the current system, and physician performance will be evaluated against specifically determined measures. Payments will increase or decrease based on the outcome and level of provider care.

Consolidated Reporting

Under MACRA, the Merit-based Incentive Payment System (MIPS) will consolidate three existing quality-reporting programs: the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM) and meaningful use (MU). It will also add a new performance category called improvement activities (IA). Physicians will be scored on each of the four categories: quality, resource use, advancing care information and clinical practice improvement activities. Their score, which will total 0 – 100, will determine the physician’s payment adjustment.

What else will MACRA do?

Not only does MACRA address new payment structures, but it also includes funding for necessary technical assistance to providers and for Quality Measure Development. It will enable new programs and create strict requirements for critical and accurate data sharing.

MACRA will substantially impact the healthcare system as it works to provide better care, smarter spending, and healthier patients by focusing on physician incentives, superior care delivery, and comprehensive information sharing.

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