End-of-Year Is Here: Keeping Up with CMS

It is that time of year, again! Quality reporting is upon us, and Enterprise Health wants to keep you informed of the basics:

End-of-Year Approaching

With the 2019 performance year ending December 31st, it is important to ensure you are enrolled and ready for attestation, if necessary. Here’s what you need to do to prepare for the new year!

  1. Using a National Provider Identifier (NPI), check the participation status  for each eligible clinician.
  2. Participants should ensure enrollment has been completed successfully .
    1. Deadline for submitting a PI Hardship Exception Application - December 31, 2019
    2. Deadline for submitting a QPP Extreme and Uncontrollable Circumstance Exception Application - December 31, 2019
    3. 2019 Performance Data Submission window is January 2, 2020 - March 31, 2020
  3. Determine data submission method and submit performance data:
    1. Self-attestation via file submission ; or
    2. Reach out for assistance and consulting, if necessary ($250/hr)

Enrollment and Attestation

As noted, enrollment is as simple as first checking your participation status . Once participation is confirmed, follow these enrollment steps :

  1. Navigate to the Quick View from the sidemenu, and locate the Quality Reporting portlet.
    1. If the Quality Reporting portlet is not enabled, click the Select Portlets link toward the top of the page. Select the Quality Reporting portlet, and click the Save button.
  2. Click the Enroll hyperlink to begin the enrollment process.
  3. After the page loads, use the Opt In section to begin enrolling users, accordingly. Begin typing into the User autocomplete each name of the user(s)/provider(s) being enrolled. Multiple users/providers may be enrolled at one time.
  4. If enrolling in a specific program, or one of the sponsored incentive programs, specify the Start/End Dates of the intended performance period. Otherwise, leave blank.
  5. Next, from the Available Measures table, select all measures needing to be tracked, specific to the relevant program(s) opted into by the enrolled provider(s). Filter the columns, as needed.
  6. Once all necessary measures have been selected, click the Submit button.

Guided Enrollment

As a means to assist with determining the necessary number of measures associated with a given program, or to simply guide the process of enrollment, Enterprise Health offers links to help drive the overall process.

To begin, perform the following:

  1. Navigate to the  Quick View  from the sidemenu, and locate the Quality Reporting portlet.
  2. Click the  Enroll  hyperlink to begin the enrollment process.
  3. After the page loads, click the Guided Enrollment link. The guided process will categorize and group the measures and walk users through the steps and requirements associated with the MIPS program, offered through the Centers for Medicare and Medicaid Services (CMS).
  4. When the page loads, Instructions will display at the top of the page. Review these instructions and continue through each section of the program, as appropriate.
  5. Use the Opt In section to begin enrolling users, accordingly. Begin typing into the User autocomplete each name of the user(s)/provider(s) being enrolled. Multiple users/providers may be enrolled at one time.
  6. Because MIPS requires particular reporting periods for its measure categories, be sure to specify the Period for each performance category. Understand that all users/providers specified will be enrolled for the same period and measures selected. If different measures and periods are required for different users/providers, perform this step with each user/provider, individually.
  7. When all of the measures have been selected for the performance category, click the Submit button.
<strong>Be sure to enroll in ONLY the measures for which supporting documentation can be provided, as outlined by the measure specification. DO NOT enroll in any measures for which supporting documentation cannot be provided in the event of an audit.</strong>
8. If there are any additional performance categories, the page will refresh and load the instructions and Opt-In block, again, as well as any measures offered under that category. Follow the provided instructions and select any and all appropriate measures. Click the Submit button when ready to continue. 9. Continue until all categories of the program have been updated. 10. Once all categories are addressed and measures are successfully selected and submitted, Status for All Providers (enrolled) will display in grid form.

Create a File for Submission

Attesting and submitting data with Enterprise Health is as simple as generating a file for submission and utilizing the QPP Submission Portal , or the like, to deliver the data, as needed. If you are not interested in self-attestation and would like assistance and consultation for data submission, please feel free to reach out. We are able to help and consult on attestation for $250/hr.

The following instructions outline the general process for generating a file from the Enterprise Health system, which then allows administrators to submit the certified data, as needed, to the appropriate organizations:

Be sure to enroll in ONLY the measures for which supporting documentation can be provided, as outlined by the measure specification. DO NOT enroll in any measures for which supporting documentation cannot be provided in the event of an audit.
  1. Log into the  Enterprise Health system.

  2. Navigate to the Reports sidemenu.

  3. Go to the Quality of Care reports and tools.

  4. Under Tools, select  Reporting Document Generator.

  5. The generator allows users to specify reporting years, select specific participants/providers, or limit individual categories from the report, as appropriate. After selecting the appropriate values, click the Download Reporting Document(s) button.

  6. When Download Reporting Document(s) is clicked, the page will automatically download the appropriate number of files, based on the number of participants specified in the file criteria. If multiple participants are selected, an individual file will be generated for each participant, appending the Provider ID to the filename.

  7. Be sure to Save the file(s) to your device.

  8. With the file(s) saved to the device, navigate to the submission portal to upload the generated file(s).

2020 QPP Final Rule

As is typically the case, CMS finalized a great deal of changes for the upcoming years. One of these anticipated changes is a participation framework that is expected to begin with the 2021 performance period. The MIPS Value Pathways (MVPs) framework aims to align and connect measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories for different specialties or conditions. For more on this, be sure to watch The Future of MIPS YouTube video and check out the progression of the MIPS Value Pathways (MVPs) webpage .

Additionally, changes for third-party intermediaries (i.e., QCDRs and Qualified Registries) have been finalized to take effect as early as PY 2020. There will be a requirement of QCDRs, beginning with the 2020 performance period, to work together to harmonize their similar QCDR measures. Beginning with the 2021 performance period, QCDRs and Qualified Registries will be required to consolidate and enhance their services by supporting all MIPS performance categories that require data submission, as well as provide enhanced performance feedback, allowing clinicians to view their performance on a given measure in comparison to other participants in the registry or QCDR.

Due to the ongoing changes and updates needed for 2020 compliance, Enterprise Health will need all clients currently participating in quality surveillance, incentive programs, or measure tracking to upgrade to RC201909. Without an upgrade to RC201909, clients will not be able to enroll or participate in quality of care programs in 2020. Application Support will be reaching out to all participating clients** to initiate conversations, answer questions, and address roadblocks or challenges this necessary upgrade may present.**

For the 2020 performance period, the following high-level changes can be noted:

  • The performance threshold is 45 points
  • The additional performance threshold for exceptional performance is 85 points
  • There are no changes to the performance category weights from PY 2019

Quality Performance Category

  • Data completeness threshold increased to 70%
  • Flat percentage benchmarks have been established in limited cases where CMS determines that the measure’s otherwise applicable benchmark could potentially incentivize treatment that could be inappropriate for particular patients
  • Added new specialty sets:
    • Speech Language Pathology
    • Audiology
    • Clinical Social Work
    • Chiropractic Medicine
    • Pulmonology
    • Nutrition/Dietician
    • Endocrinology

Cost Performance Category

  • Revised the Medicare Spending Per Beneficiary Clinician and Total Per Capita Cost measures
  • Added 10 new episode-based measures to continue expanding access to this performance category

Improvement Activities Performance Category

  • Updated the patient-centered medical home criteria, removing the reference to the four listed accreditation organizations to be recognized as patient-centered medical homes and removing the reference to the specific accrediting organization for comparable specialty practices
  • Added 2 new, and removed 15 existing, Improvement Activities; established factors for consideration for removal
  • Increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice needing to perform the same improvement activity.
    • Groups must perform the same activity during any continuous 90-day period within the same performance year

Promoting Interoperability Performance Category

  • Removed Verify Opioid Treatment Agreement measure
  • Included the Query of Prescription Drug Monitoring Program (PDMP) measure as an optional measure (available for bonus points)
    • Beginning with PY 2019, a “yes/no” response is required for the optional Query of PDMP measure, instead of a numerator and denominator
  • Reduced the threshold for a group to be considered hospital-based
    • Instead of 100% of clinicians, more than 75% of clinicians in a group must be a hospital-based individual MIPS-eligible clinician in order for the group to be excluded from reporting the measures under the PI performance category and to have this category reweighted to zero.

Keeping On Keeping On

Stay up-to-date with us! Always check back to our Online Documentation and be sure to review our published communications  for news and updates, regularly! Otherwise, administrators can view all of our Latest news in the Enterprise Health system, found under the Administrator Welcome portlet of the Quick View.


Enterprise Health Documentation

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