QUALITY PAYMENT PROGRAM SMALL UNDERSERVED RURAL SUPPORT (QPP SURS) WEBINAROCTOBER 16, 3:30 PM ET AND OCTOBER 18, 11:00 AM ET

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SUBMITTING YOUR 2018 MIPS DATA: ADVICE FOR SOLO AND SMALL GROUP PRACTICES

SUBMITTING YOUR 2018 MIPS DATA

HOUSEKEEPING ANNOUNCEMENTS

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If you are listening to this webinar through your phone, please remember to mute your computer speakers.

For assistance, enter your issue in the chat box.

To ask a question, enter your inquiry in the chat box.

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SUBMITTING YOUR 2018 MIPS DATA

POLLING QUESTIONWhat is your role?▸

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A clinician working in a practice with 15 or fewer clinicians

Non clinical staff from a practice with 15 or fewer clinicians

A clinician working in a practice with more than 15 clinicians

Non clinical staff in a practice with more than 15 clinicians

Quality Payment Program (QPP) contractor

Other person helping practices prepare for MIPS

Other

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SUBMITTING YOUR 2018 MIPS DATA

POLLING QUESTIONHow are you planning to submit your 2018 MIPS data?▸

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I am submitting as an individual

I am submitting as a group

I am submitting as a virtual group

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SUBMITTING YOUR 2018 MIPS DATA

POLLING QUESTIONWhat are your biggest expected challenges or concerns with using the QPP Portal to submit data?

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CMS WELCOME6

Brenda Gentles, RN, BS, MS

Division of ESRD, Population & Community Health

Centers for Medicare & Medicaid Services

QPP SURS Central Support Contractor COR

SUBMITTING YOUR 2018 MIPS DATA

Bruce Spurlock, MDPresident & CEO,Cynosure Health

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Michael Sacca, Managing Director, IMPAQ Health

Division, QPP SURS Central Support

Daniel Day, Hospital and Physician Office Quality

Improvement Advisor for AQAF

SUBMITTING YOUR 2018 MIPS DATA

SETTING THE STAGE▸

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Focus: Understanding the methods by which you can submit your 2018 MIPS data

Strategy: Discussion with panelists who are familiar with the range of data submission options available to small group practices and individual clinicians

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Topic Overview:

Who is required to submit MIPS data?What you need to know before you get startedOptions for submitting in each of the four performance categoriesHow best to prepare for the 2018 submission periodFree resources!

Using the Chat Box

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SUBMITTING YOUR 2018 MIPS DATA

POLLING QUESTIONWhat are you most looking forward to learning about on today’s webinar?

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SUBMITTING YOUR 2018 MIPS DATA

RESOURCES FOR FREE SUPPORT10

Technical Assistance Organizations

Free technical assistance and advice available for small practices from CMS-funded organizations. Contact information for each organization at: https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf

• General information about QPP for eligible clinicians participating in MIPS or Advanced APMs: https://qpp.cms.gov/

• Questions to CMS about Quality Payment Program:QPP@cms.hhs.gov

• Sources of support for larger practices and APM participants described in: https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf

QUESTION:

Am I required to submit MIPS data and what do I need to know before I get started?

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SUBMITTING YOUR 2018 MIPS DATA

ELIGIBILITY REQUIREMENTS▸

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For 2018, you’re required to participate in MIPS if you are an eligible clinician type, AND if you exceed the low-volume threshold.The low volume-threshold is applied at both the individual and at the group level.Review of exemption criteria

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ELIGIBILITY REQUIREMENTS13

SUBMITTING YOUR 2018 MIPS DATA

WHERE CAN I CHECK MY ELIGIBILITY?▸

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Clinicians can use the CMS NPI lookup tool to check their eligibility: https://qpp.cms.gov/participation-lookup

The tool contains eligibility information for ALL practices you are associated with

The NPI lookup took can also be used to view special status information

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MIPS REPORTING OPTIONS15

SUBMITTING YOUR 2018 MIPS DATA

MIPS YEAR 2 PERFORMANCE PERIOD AND TIMELINE

▸ 2018 Data Submission Infographic

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Quality—12 monthsCost— 12 monthsIAs — continuous

90 daysPI — continuous

90 days

SUBMITTING YOUR 2018 MIPS DATA

MONITORING YOUR DATA17

▸You can monitor your data all year long!

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Check and review your quality data codes for claims

▸Verify and retain your Part B Remittance Advice/Explanation of Benefits transmittals.

Use of MIPS calculator.

Monitor vendors and regularly review reports.

QUESTION:

How do I get started submitting my data through the QPP portal?

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SUBMITTING YOUR 2018 MIPS DATA

WHO NEEDS A CMS ENTERPRISE IDENTITY MANAGEMENT (EIDM) ACCOUNT

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Clinicians, groups, MIPS APMs, and certain Advanced APM participants that:

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Will be submitting data directly to qpp.cms.gov (QPP portal)

Have secured an EHR/Health IT Vendor to submit their data to the QPP portal

Want to view the data submitted on their behalf by a third party

Qualified Clinical Data Registries, Qualified Registries, and EHR/Health IT Vendors that will be submitting data directly to the QPP portal on behalf of their clients

CMS Enterprise Portal: https://portal.cms.gov/wps/portal/unauthportal/home

SETTING UP OR RENEWING YOUR ACCOUNT▸

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Your account will lock after 60 days of inactivity.

▸Your password must be changed at least every 60 days and can only be changed once a day.

Your account will deactivate if you have not logged in for more than 180 days.

▸To reinstate your account, call the Quality Payment Program Service Center at 1-866-288-8292 | TTY: 1-877-715-6222 or via e-mail at qpp@cms.hhs.gov Monday through Friday 8am-8pm ET.

To set up a new account or for general information on EIDM access for QPP, please review:

▸EIDM User Guide

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QUESTION:

What are my options for submitting my 2018 quality measures?

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SUBMITTING YOUR QUALITY DATA▸

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Claims (individuals only)

Qualified Clinical Data registry (QCDR)

Qualified Registry (QR)

Electronic Health Record (EHR)

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SUBMITTING YOUR QUALITY DATA—CLAIMS▸

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Clinicians pick from 73 available measures and report through their routine billing processes.

Same claims forms you’ve traditionally submitted to CMS for payment for the services you’ve performed, but also add Quality Data Codes (QDCs) to denominator eligible claims as defined by the measure specification.

For assistance in identifying denominator eligible cases based on the patients you see, and for more details on submitting QDCs, visit the 2018 Claims data submission fact sheet.

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SUBMITTING YOUR QUALITY DATA—QCDR AND QR

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QCDRs collect medical and/or clinical data to track patients and disease and submits to CMS on your behalf.▸▸

Each QCDR usually gives customized instructions about how to submit data. You can find approved QCDRs in the 2018 QCDR qualified posting.

A Qualified Registry collects clinical data and submits to CMS on your behalf. ▸ You can find approved Qualified Registries in the 2018 Qualified Registries qualified

posting.Based on the terms of your agreements, both QCDRs and QRs will submit data on your behalf via the QPP portal. ▸Quality data submitted by QRs and QCDRs is uploaded via QPP data format (JSON,

XML) or Quality Reporting Document Architecture (QRDA III).

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SUBMITTING YOUR QUALITY DATA—EHR ▸

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You can submit your quality data collected through your certified EHR technology (CEHRT) – either the 2014 or the 2015 Edition CEHRT.

You can submit yourself via the QPP portal or by working with a certified health IT vendor who will submit the data on your behalf.

▸The data will be submitted via the QRDA III file format by you or your health IT vendor.

Groups and Virtual Groups that collect data using multiple EHR systems will need to aggregate their data before it’s submitted.

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SUBMITTING YOUR QUALITY DATA—PRACTICAL TIPS

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Review your data to make sure the percentages on the QPP portal dashboard are the same as in the file you are uploading.If you notice an error contact your vendor or Quality Payment Program Service Center at 1-866-288-8292.Some EHRs do not have the ability to report Quality data at the Group level. In this case you can either submit individually or hire a company to combine the individual QRDA III files.Engage your EHR vendor early and often!

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QUESTION:

What are my options for submitting my 2018 improvement activities?

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IMPROVEMENT ACTIVITY REQUIREMENTS▸

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15% of your final 2018 MIPS score.Choose from the 113 available Activities that best meet the need of your practice.Meet 90-day requirement (activities that you performed for at least 90 consecutive days).MIPS eligible clinicians in small practices can report on just 2 medium weighted or 1 high weighted IA activity to earn the maximum number of points.▸

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1 high-weighted activity OR2 medium-weighted activities

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Improvement Activities submitted by designated small practices receive double the points!

20 points for medium-weighted activities 40 points for high-weighted activities

SUBMITTING YOUR 2018 MIPS DATA

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For 2018, you must chose one submission method.

You can log onto the QPP portal and manually attest to the improvement activities that you completed.

A third party vendor (QCDR, QR, or EHR) can submit your IA data on your behalf by uploading data via the QPP format (JSON, XML) or a QRDA III file.

Keep documentation for 6 years.

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IMPROVEMENT ACTIVITY PRACTICAL TIPS

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If your third-party vendor is able to create an IA QRDA III file and is submitting it on your behalf, there is no need for you to upload additional data for the activity/activities.

When attesting in the portal, be sure to put in at least a 90-day continuous date range for the performance period as the QPP portal will give you an error message for any performance period inserted that is less than 90 days.

Note: some activities’ performance period are longer than 90-days, so be sure to check the activity specifications.

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QUESTION:

What are my options for submitting data in the promoting interoperability performance category?

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PI—REQUIREMENTS▸

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Use certified EHR technology.

Submit the performance period (a minimum of 90 consecutive days period in 2018).

Submit a “yes” to the Prevention of Information Blocking Attestation.

Submit a “yes” to the ONC Direct Review Attestation.

Submit a “yes” for the security risk analysis measure, and at least a 1 in the numerator for the remaining base score measures or submit an exclusion for the base score measures.

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SUBMITTING YOUR 2018 MIPS DATA

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You can log onto the QPP portal and manually attest to the PI measure that you completed or manually upload a file.

A third party vendor (QCDR, QR, or EHR) can submit your PI measures on your behalf by uploading a file in the QPP Data Format (JSON, XML) or QRDA III format.

You must use certified EHR technology to report or attest to PI.

Review your EHRs’ dashboard to identify the PI data you are submitting for the last 90 days.

Reweighting application is due December 31, 2018. To submit an application visit: https://qpp.cms.gov/mips/exception-applications

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SUBMITTING YOUR 2018 MIPS DATA

PI—PRACTICAL TIPS▸

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No more PI measure performance thresholds!▸▸

Submit PI measure data to build towards your score. The more measure data you submit, the more opportunity you have to increase your performance category score!

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Similar to IA, you first need to designate a performance period. Select one of the measure sets that are available (PI measures vs. 2018 PI Transition measures). Your EHR plays a role in which measure set you choose.Submit the two required attestation statements. Finally, every single measure available within the Required Base Score selection must be attested with positive values (along with attesting that “yes” you completed the Security Risk Analysis measure) in order to begin populating a category score. ▸ OR if you meet the measure exclusion(s), choose the exclusion.

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QUESTION:

What about cost data submission?

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COST ▸

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Review your MIPS Cost performance category feedback in the QPP Portal.▸ The Cost performance feedback shows how groups or solo practitioners performed

on the two cost measures.Reference historical information from the Physician Value-Based Payment Modifier Program.▸ Quality and Resource Use Reports (QRUR) showed how clinicians and groups

performed on similar measures.▸ You can access you QRUR here:

https://portal.cms.gov/wps/portal/unauthportal/home/

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COST—PERFORMANCE FEEDBACK ▸ You can access your performance feedback on cost measures via the QPP portal.

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QUESTION:

What should I be doing now to prepare for the data submission period?

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PRACTICAL ADVICE

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Don’t wait to get started.

Make sure your EIDM account is set up and current.

Understand your agreements with vendors.

Work with your Technical Assistance Contractors sooner than later.

Review and monitor all year long!

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QUESTION:

If I still need help, where can I go?

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FREE RESOURCES FOR ASSISTANCE FROM CMS▸

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QPP website: https://qpp.cms.gov/--includes information tailored for the needs of small practices https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-Events.html

Contact the Quality Payment Program at: QPP@cms.hhs.gov or call 1-866-288-8292

Support and Available resources for Small, Underserved, and Rural Practices: https://qualitypaymentprogram.cms.gov/about/small-underserved-rural-practices

Small Underserved Rural Support Technical Assistance Organizations (see list on slide 10)

Contact information is available at: https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf

Available websites of each Technical Assistance Organization

Types of help: needs assessments, webinars, technical support, links to peers you can talk with, assistance getting signed up to report through an approved channel that meets your practice’s needs

FREE Technical Assistance funded by CMS is also available for larger group practices and for clinicians interested in participating in an Alternative Payment Model. More information on those programs is available at: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Technical-Assistance-Resource-Guide.pdf

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FREE RESOURCES FOR ASSISTANCE FROM CMS

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CMS Data Submission instructional videos :

Merit-based Incentive Payment System (MIPS) Data Submission

Advancing Care Information (ACI) Data Submission for Alternative Payment Models (APMs)

Data Submission via a Qualified Clinical Data Registry and Qualified Registry

Data Submission fact sheet

QPP Participation Status Lookup Tool

2017 Performance Review Fact Sheet

2017 Payment Adjustment Fact Sheet

2018 Quality Payment Program Participation Infographic

2018 Data Submission Infographic

2018 MIPS Scoring 101 Guide

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WRAP-UP ACTIVITIES▸

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Links to Q&A documents, transcripts, and recordings of the event are available here: https://qppsurs.wordpress.com/resources/November: Overview of the 2019 Final Rule: Implications for Solo and Small Group Practices

Please provide feedback on this event: Feedback Form

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REFERENCESSlide decks created by event panelists also provided information reflected in this presentation. The input from project panelists is gratefully acknowledged.Other documents on the https://qpp.cms.gov/ and https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Resource-library.html website provide additional detail about the MIPS program.Disclaimer: This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes periodically so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

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APPENDIX: FREQUENTLY ASKED QUESTIONS

When is the 2018 performance period data submission period?The 2018 Performance Year data submission window is from January 2, 2019 – April 2, 2019. You may submit and update your data any time while the submission window is open.

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APPENDIX FREQUENTLY ASKED QUESTIONS:Where is the ‘Submit’ button in the portal?There is no more submit button! The application for submissions around QPP was designed with real-time scoring and feedback built in to the functionality for that application.

That said, any data that is submitted to the application, whether attested on the user interface (UI) or submitted through a file upload or data coming in through other sources, is actually stored and evaluated in real time.

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APPENDIX: FREQUENTLY ASKED QUESTIONSOnly the most favorable MIPS Final Score for a TIN-NPI is attributed to a TIN-NPI. But how does that play into submissions?Where there is a group and an individual submission, there is no combining of methods, so there would be a submission for an individual and a submission for a group. The only way that the TIN-NPI would actually be used as the submission would be if the overall submission score is higher than the group’s. It takes into consideration the other two categories, as well. So, that individual would need to go in and submit as an individual for the PI and IA categories too. Otherwise, the group score, most likely by default if the group is reporting all three categories, is going to be higher.

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APPENDIX: FREQUENTLY ASKED QUESTIONSWhy is it that only one submission method is being scored despite having those multiple submission methods present?In the QPP portal during the submission period, you’ll be able to see that data was submitted by you, or on your behalf by a third party, for EACH performance category. At the end of the data submission period, the single submission mechanism (QCDR, QR, attestation, EHR, etc.) that resulted in the highest performance category score will be your score for that performance category and will contribute towards your MIPS Final Score.

NOTE: Data will not be aggregated across submission mechanisms to calculate your highest possible score for a performance category.

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APPENDIX: FREQUENTLY ASKED QUESTIONSWhy is my score no longer increasing although I am continuing to attest to Improvement Activities or Promoting Interoperability measures after seeing the 'Category Success' message (in the portal)? In the QPP portal during the submission period, if you are seeing that message that you've achieved category success, and you're seeing a category score that appears to be maxed out, you will, in the user interface or file upload, be allowed to continue uploading or attesting for additional measures and activities, and are encouraged to do so in order to submit additional relevant information. However, each of the various category scores does have a maximum score that can be achieved. So, once it has been achieved, additional measures submitted will not further impact the category score.

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APPENDIX: ACRONYMSAPM – Alternative Payment ModelACO – Accountable Care Organization ACI – Advancing Care InformationCERT—Certified EHR TechnologyCMS – Centers for Medicare & Medicaid ServicesER— Emergency RoomEOB— Explanation of BenefitsEIDM— Enterprise Identity Data Management MIPS – Merit-based Incentives Payment SystemPCMH— Patient Centered Medical Home

PI— Promoting Interoperability PQRS— Physician Quality Reporting SystemIA – Improvement ActivitiesEHR – Electronic Health Records QCDR—Qualified Clinical Data RegistryQPP – Quality Payment ProgramQRDA – Quality Reporting Data ArchitectureQRUR— Quality and Resource Use ReportsSURS - Small Underserved Rural Support TIN—Tax Identification Number

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