MIPS Reporting: Submitting Data through QPP.CMS.GOV. Sam Ross, QPP Advisor/Manager January 31, 2018

Transcription

1 MIPS Reporting: Submitting Data through QPP.CMS.GOV Sam Ross, QPP Advisor/Manager January 31, 2018

2 Visit our website at We will help you navigate the complexities of the new CMS payment models so you can focus on what you do best taking extraordinary care of your patients. When you sign up for the QPP Resource Center, you get access to resources that help you establish your baseline, identify goals, learn about requirements, and monitor progress. Plus, QPP Advisors are available to answer questions as they come up. All assistance is offered free-of-charge thanks to a grant from CMS.

3 Agenda Brief MACRA/QPP Overview QPP.CMS.GOV Sign In and Navigation Entering Data for MIPS Categories Quality Advancing Care Information Improvement Activities Additional Considerations and References

4 Brief MACRA/QPP Overview

5 MACRA (2015) Repeals Sustainable Growth Rate Streamlines multiple quality programs Expands pathways for level of risk and reward Supports multi-payer initiatives

6 2017 QPP Eligibility 1) Billing > $30,000 and treating 100+ Medicare patients per year (MIPS) or 2) Treating 20% patients/receiving 25% of Medicare payments through an Advanced Alternative Payment Model (AAPM) Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Models (AAPM)

7 2017 QPP Timeline

8 Sign In and Navigation

9 QPP Home Page Visit Click Sign In at top right

10 QPP Sign In Page Enter EIDM User ID and Password Click the box for Yes, I agree. to the statement of truth Click the Sign In button

11 Verify One-Time Code A code will be sent to the Multi-Factor Authentication (MFA) device registered with EIDM account (phone, , voice) Retrieve the code, enter into the text box, and click Submit Code button

12 Account Dashboard Practices for which your EIDM account can submit are displayed Special status (small practice, non-patient facing, HPSA, rural, hospitalbased, ASC) identified for each practice

13 Manage User Access Page Click Manage User Access Connected practices and permissions display with link to CMS Portal to add/update/remove user access to TINs through EIDM account

14 Help and Support Page Click Help and Support Click any button to navigate to that support section (videos, webinars, etc.)

15 Collapse/Expand Click Collapse to shrink the side navigation bar for more page real estate Click Expand to return to normal size side navigation bar Expanded Collapsed

16 Accessing the Reporting Module Click Account Dashboard Click As a group or As individuals under the REPORT header

17 Side Navigation Group vs Individual Side navigation shows practice name and TIN when using group reporting Side navigation also shows clinician name and NPI when using individual

18 Group Reporting Dashboard Click category to report from navigation side bar OR Click Start Reporting button under category name

19 Connected Clinicians (Individual Reporting) Individuals linked to the group TIN will appear under Connected Clinicians * Enter reporting module for each MIPS category by clicking category name under the REPORT header (next to clinician you are reporting for) * If clinicians for whom you need to report are missing, they must be linked to the practice/tin through PECOS at

20 Entering Data for MIPS Categories: Quality

21 Quality No Existing Data Option 1: Upload QRDA or QPP file (self-submission) Option 2: Contact registry/cehrt for support with submission on your behalf Click File Upload button to upload your own file

22 Upload Submission Data Click browse when the pop-up window appears

23 Upload Submission Data Find the file on your computer and click Open

24 Upload Submission Data File(s) will display with option to upload/remove one file at a time or all at once

25 Upload Submission Data - Errors File(s) will display with a status of Upload Failed Click Upload Failed to review errors, which can be sent to CEHRT technical support for analysis to fix issues with QRDA/QPP file formatting

26 Upload Submission Data - Success File(s) will display with a status of Complete Click the Close button to exit the upload pop-up window and review data that was included in the file

27 Quality Existing Data File Upload button still exists to over-write previous upload Delete Category Data button will remove data previously uploaded Score(s) by submission method display below

28 Measures that Count Scroll down to see summary of submission System automatically picks best 6 measures that count towards Quality Each measure will display performance rate and score

29 Measure Details Click the > icon to the left of a measure name to show details Displays performance against benchmark and explanation of points earned from decile performance and bonus

30 Measures with Bonus Points Scroll down to see all measures that earned bonus points Bonus for high-priority/patient experience measures, outcome measures and/or measures submitted via end-to-end electronic reporting

31 Measures Submitted but Not Counted Scroll down to see all measures included in QRDA/QPP file that were not in the top 6 and do not count towards Quality score Can still click > icon to review details on benchmark and points that would have been earned if the measure were in the top 6

32 Quality Additional Submission Methods If additional data is uploaded (by you or on your behalf by CEHRT/registry vendor) via another submission method, an additional score will display Click View Details in the greyed out section to review measures System will display both but automatically choose your highest score

33 Entering Data for MIPS Categories: Advancing Care Information

34 Advancing Care Information No Existing Data Option to use File Upload with QRDA/QPP file (same as Quality) Otherwise, start by selecting your performance period

35 Select Measure Set Each measure set is described To identify what CEHRT supports, enter keyword in box (optional) Click Search to query products listed on the CHPL

36 Select Measure Set Pop-up window appears with search results Click the version of the product you used during reporting period

37 Select Measure Set After choosing product, pop-up window will close Based on CEHRT Edition Year, select from available measure sets

38 Attestation Statements Before entering ACI measure results, you must review and respond to three attestation statements Click the > icon to expand and view entire statement First two statements require agreement (click Yes ) Third statement is optional agreement

39 Enter Measure Data Base Score First section will be measures required for base score Must enter numerator/denominator or answer Yes/No for all Pink thumbs up icon indicates measure is met

40 Enter Measure Data Performance Score Next section is Optional Performance Measures Enter numerator/denominator or answer Yes/No Performance score points for each measure displays after answering Category score updates in real time as you add data (pink bar at top)

41 Enter Measure Data Bonus Score Next section is Additional Registry Bonus Answer Yes/No to each registry reporting measure Bonus score points display after answering each question

42 Enter Measure Data Improvement Activities Bonus Last section is Improvement Activities Bonus Answer Yes/No to the question System alerts if you have not attested to any Improvement Activities that qualify for a bonus, with link to Improvement Activities page Bonus score points display after answering ( N/A if no points earned)

43 Entering Data for MIPS Categories: Improvement Activities

44 Improvement Activities No Existing Data Option to use File Upload with QRDA/QPP file (same as other categories) Otherwise, start by selecting your performance period Performance period must be at least 90 days to earn any points

45 Search for Activities Click Filters to filter by sub categories, weight or CEHRT bonus eligible Enter search terms to filter by keyword

46 Advancing Care Information CEHRT Version Click Yes to select activity (turns into green check mark) Category points will update after selection, with Category Success noted in upper right when reaching maximum score

47 Additional Considerations and References

48 Additional Considerations There is no submit or save button anywhere on the QPP submission site Data can be added/deleted/updated until window closes on 3/31 CMS will automatically accept data resulting in the best score Same website will be used to show final scores, comparison against national results, and payment adjustments (scheduled for summer)

49 Additional Considerations Quality Download/request QRDA file from your CEHRT vendor and test upload Data submitted via claims or CMS Web Interface will not display(?) Data submitted by ACO will not display(?) Advancing Care Information Download/request QRDA file (upload) or ACI report (manual attestation) from your CEHRT vendor Only required category for ACO practices to self-submit (report as a group) Improvement Activities Download/request QRDA file (upload) or IA report (manual attestation) from your CEHRT vendor; or document which IA you met in advance System is scoring incorrectly for small practices Should score medium-weight = 20, high-weight = 40 CMS has assured this will be fixed/scored correctly

50 References

51 THANK YOU!! Quality Payment Program of Illinois QPP-DESK ( )