Dec 14, 2017 - Questions & Answers: What do I need to do for the 2017 performance year related to attesting to Infor
Quality Payment Program Office Hours December 14, 2017 Questions & Answers: What do I need to do for the 2017 performance year related to attesting to Information Blocking? The final rule states that eligible clinicians must attest as part of the Advancing Care Information category that they are not intentionally blocking the electronic flow of electronic information. Here is a link to a fact sheet from CMS providing more details regarding this attestation: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/ACI-Information-Blocking-fact-sheet.pdf How will Centers for Medicare & Medicaid Services (CMS) know if an eligible clinician is reporting as an individual or as a group? Once CMS opens up the attestation portal, eligible clinicians will be able to select between individual and group reporting. When will the CMS portal be available? The CMS Portal will be available for reporting starting on January 2, 2018. The link to the MIPS reporting portal is available here: https://qpp.cms.gov/login. To sign in to QPP, you need to use your Enterprise Identity Management (EIDM) credentials, and you must have an appropriate user role associated with your organization. You may have used these credentials in the past to login to the CMS Enterprise Portal and/or to submit data to the Physician Quality Reporting System (PQRS). I am trying to get us some documentation to prove that we are actively doing that particular activity. Is the documentation I am gathering to be dated sometime during that 90-day period that we are testing for? That is our recommendation for both attestation and auditing purposes. Could you provide clarity regarding the data completeness threshold? The 50 percent data completeness threshold are: CLAIMS: completed for at least 50 percent of the denominator for Medicare Part B beneficiaries. ALL OTHER METHODS: completed for at least 50 percent of the denominator for all payers.
Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. www.lsqin.org | Follow us on social media @LakeSuperiorQIN
For the improvement activities category, what degree of documentation we need to show to prove that every provider participated in the improvement activity and I guess furthermore, what is the definition of participated? First, for all improvement activities, if you are reporting as a group, only one clinician has to be doing and attesting to the activity for the entire group to get credit for the activity. We would recommend that you follow the guidance in the Merit-Based Incentive Payment System (MIPS) validation Tool on the Quality Payment Program (QPP)/CMS web site for determining what documentation you would need to prove that you did the activity. For the Improvement Activity category, if we are going to attest for a large group of providers, I do not have to demonstrate or have documentation for each individual provider, do I? As long as I have documentation showing one or two providers, will that be sufficient? One provider within a group needs to have the documentation, and that will carry the entire group. Will the Stratis Health MIPS Estimator aggregate my scores as a group? Yes, if you enter in each one of your individual clinicians, the estimator will aggregate the scores as a group. We have a situation where we have a provider who sees patients in various nursing homes. We have always applied for hardship exceptions for these providers. This year, we have a number of mid-levels that are part of that same group. Looking over the instructions on how to file a hardship for 2017, there is a special status for these kinds of clinicians that indicates I may not need to file a hardship for these mid-levels. Is this correct? You do not need to file a hardship exemption for the advancing care information category for those clinicians who were not required to report under Medicare meaningful use last year. They are automatically exempt. You do have to include them with your quality scores. Before you decide to exclude them, you will want to look at their numbers to see if including their data in the ACI category actually brings your scores up. Remember that if you exclude them in the ACI category, their ACI weight will go to the Quality category which will raise it from 60 percent to 85 percent.
Disclaimer: Information provided in this presentation is based on the latest information made available by the Centers for Medicare & Medicaid Services (CMS) and is subject to change. CMS policies change, so we encourage you to review specific statutes and regulations that may apply to you for interpretation and updates.
Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. www.lsqin.org | Follow us on social media @LakeSuperiorQIN This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D1-17-183 121917
