Quality Payment Program

2020 Self-Nomination Application Demo Webinar

June 11, 2019

Disclaimers

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, 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.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

2

3

Agenda

• Self-Nomination Information

• Self-Nomination Demonstration

• QCDR Measure Submission Template Information

• QCDR Measure Submission Template Demonstration

• Resources & Who to Call for Help

• Question & Answer Session

SELF-NOMINATION INFORMATIONHector Cariello, MIPS QCDR/Registry Support Team (PIMMS Team)

4

5

What is a QCDR?

• A Qualified Clinical Data Registry (QCDR) is defined as an entity that demonstrates clinical expertise in medicine and quality measurement development that collect medical or clinical data on behalf of MIPS eligible clinicians to track patients and diseases and foster improvement in the quality of care provided to patients.

6

What is a QCDR? (cont.)

A QCDR may include:

• An entity with clinical expertise in medicine. Clinicians must be on staff with the organization and lend their clinical expertise in the work carried out by the organization as a QCDR.

• An entity with stand-alone quality measurement development.

• An entity that collects medical or clinical data on behalf of a MIPS eligible clinician for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.

• An entity that uses an external organization for purposes of data collection, calculation, or transmission may meet the definition of a QCDR as long as the entity has a signed, written agreement that specifically details the relationship, roles, and responsibilities of the entity with the external organization effective as of September 1 the year prior to the year for which the entity seeks to become a QCDR.

7

What is a QCDR? (cont.)

Entities without clinical expertise in medicine and quality measure development that want to become a QCDR, may collaborate with entities with such expertise. Entities may seek to qualify as another type of third-party intermediary, such as a Qualified Registry. Becoming a Qualified Registry does not require the level of measure development expertise that is needed to be a QCDR that develops measures.

8

What is a Qualified Registry?

• A Qualified Registry is defined as a medical registry, a maintenance of certification program operated by a specialty body of the American Board of Medical Specialties or other data intermediary that, with respect to a particular performance period, has self-nominated and successfully completed a vetting process (as specified by CMS) to demonstrate its compliance with the MIPS qualification criteria specified by CMS.

• Like a QCDR, a Qualified Registry is a vendor that collects clinical data from an individual MIPS eligible clinician, group, or virtual group and submits it to CMS on their behalf. Clinicians work directly with their chosen Qualified Registry to submit data on the selected measures or specialty set of measures they have picked.

9

QCDR vs. Qualified Registry

There is one main difference between the Qualified Registry and QCDR reporting mechanisms:

• QCDRs are not limited to reporting only MIPS Quality Measures as they may submit a maximum of 30 QCDR measures for CMS consideration for the 2020 performance period of MIPS.

- Qualified Registries are not able to submit QCDR measures for consideration or support QCDR measures.

Note: Eligibility for the Eligible Measure Applicability (EMA) process is contingent on the collection type of the quality measures that are submitted, and not the submitter type (individual, group, or third party intermediary). The EMA process will not apply if QCDR measures or eCQMs are submitted.*

*This has been updated since the webinar presentation to clarify that QCDRs and Registries maybe eligible for the EMA process.

10

Participation Requirements

• When self-nominating to act as a Qualified Registry or QCDR, organizations attest to meeting the requirements set forth by the CY 2019 Physician Fee Schedule Final Rule for the Quality Payment Program, which finalized the vendor requirements for the 2020 MIPS performance period. Failure to meet these requirements may affect your ability to participate as a Qualified Registry or QCDR for future MIPS performance periods.

• Qualified Registries or QCDRs that withdraw for any reason during the performance period will be terminated as a third-party intermediary as a Qualified Registry or QCDR for future MIPS performance periods.

• A Qualified Registry or QCDR and its system must be implemented and able to accept data should a clinician, group, or virtual group wish to submit data on the approved MIPS quality measures and QCDR* measures by January 1, 2020.

*Note: QCDR Measures can only be supported by QCDRs.

11

Participation Requirements (cont.)

• Participants: You must have at least 25 participants by January 1, 2019. These participants are not required to use the QCDR or Qualified Registry to report MIPS data to CMS, but they must submit data to the QCDR or Qualified Registry for quality improvement.

• Certification Statement: During the data submission period, you must certify that data submissions are true, accurate, and complete to the best of your knowledge. This certification includes the acceptance of data exports directly from an EHR or other data sources. If you become aware that any submitted information is not true, accurate, and complete, you will correct such issues promptly prior to submission; and understand that the knowing omission, misrepresentation, or falsification of any submitted information may be punished by criminal, civil, or administrative penalties, including fines, civil damages, and/or imprisonment.

• All Payer Data: You must include quality measure results and data on Medicare and non-Medicare beneficiaries, as applicable.

12

Participation Requirements (cont.)

• Data Submission: You must submit data via a CMS-specified secure method for data submission, such as a defined Quality Payment Program data format. Additional information regarding data submission methodologies can be found in the Developer Tools section of the Resource Library of the Quality Payment Program website: https://qpp.cms.gov/developers.

• Performance Category Feedback Reports: You are required to provide performance category feedback at least four times a year to all MIPS eligible clinicians, groups, and virtual groups they are reporting for.- Please note CMS does not provide a template for the performance feedback

reports.

- If a real-time feedback dashboard is available to clinicians, CMS asks that the Qualified Registry or QCDR e-mail clinicians, groups, and virtual groups at least four times a year to remind them the feedback is available.

13

Participation Requirements (cont.)

• Clinician Information: You must verify and maintain clinician information, business associate agreements, and clinician consents. - Verification of clinician names, contact information, costs charged to clinicians,

services provided, and quality measures (MIPS quality measures and/or QCDR measures) or specialty-specific measure sets (if applicable)

- Business associate agreement(s) with clinicians or groups who provide patient-specific data must comply with HIPAA Privacy and Security Rules

- Clinician consent given to the Qualified Registry or QCDR to submit results and data to CMS for MIPS

14

Support Calls

Support Call Attendance: As communicated in the CY 2019 Physician Fee Schedule Final Rule for the Quality Payment Program and 2020 Qualified Registry and QCDR Fact Sheets, support call attendance is mandatory and unexcused absences will result in remedial action being taken against the vendor, up to and including termination of the Qualified Registry or QCDR.

• Each Qualified Registry or QCDR must have at least one representative in attendance on every support call. This applies to organizations that are supporting multiple Qualified Registries or QCDRs as one person in attendance will only count for one Qualified Registry or QCDR.

• Support call attendance is tracked via WebEx. Upon joining the WebEx, Qualified Registries or QCDRs will be asked to provide the attendee’s first name, last name, and vendor name.

15

Support Calls (cont.)

• Each Qualified Registry or QCDR must attend both the webinar and audio portion to receive credit for attending the support call.

• After self-nomination, the MIPS QCDR/Registry Support Team (PIMMS Team) maintains a distribution list that was developed based on contacts provided in the self-nomination form. Additional contacts can be added to this distribution list at any time by submitting the request to the MIPS QCDR/Registry Support Team (PIMMS Team).

- Please note that all Qualified Registries or QCDRs must have at least two different contacts on this distribution list.

16

Data Validation Plan

During self-nomination, you must thoroughly explain your process for validation of data submitted on behalf of individual MIPS eligible clinicians, groups, and virtual groups through the development of a Data Validation Plan. You are required to provide the following as a part of your Data Validation Plan:

• Name of QCDR or Qualified Registry

• Process of verifying Quality Payment Program eligibility of MIPS eligible clinicians, groups, and virtual groups

• Process of verifying accuracy of TIN/NPIs

• Process of calculating reporting and performance rates

• Process of verifying that your system will only accept data (for purposes of MIPS)

on 2020 MIPS Clinical Quality Measures, electronic Clinical Quality Measures and/or QCDR measures (QCDR only) during submission

• Process used for completion of randomized audit

• Process used for completion of detailed audit

Your Data Validation Plan will be reviewed by CMS as a part of your self-nomination application and will need CMS approval prior to its implementation for the performance period.

17

Data Validation Execution Report

You must execute your 2020 Data Validation Plan and provide us with the results (i.e., Results of the randomized/detailed audits; Were there any calculation issues? If so, why did they occur and what was done to remediate?). Execution of your Data Validation Plan must be completed prior to the 2020 performance period data submission period so errors can be corrected prior to data submission.

• The 2020 Data Validation Execution Report that includes the results of your audit, must be submitted to CMS by May 31, 2021.

- Please note, a late submission of your Data Validation Execution Report from your QCDR or Qualified Registry will be seen as non-compliance with program requirements and may result in remedial action or termination of the QCDR or Qualified Registry in future program years.

• For purposes of Qualified Registry and QCDR participation, we do not require that you provide a written report on Promoting Interoperability or Improvement Activities. However, we encourage QCDRs and Qualified Registries to utilize auditing processes to ensure the accuracy of all data submissions under the Promoting Interoperability and Improvement Activities performance categories. QCDRs and Qualified Registries certify at the time of submission, that the data submitted (for all performance categories) is true, accurate, and complete to the best of their knowledge.

18

Data Validation Execution Report (cont.)

• The following items should be addressed in the 2020 Data Validation Execution Report:

- Name of QCDR or Qualified Registry

- Results of verifying MIPS eligibility of clinicians, groups, and virtual groups (i.e., were any issues identified when determining if clinicians, groups, and virtual groups meet the MIPS eligibility requirements? If so, please provide details and examples regarding the identified issues and how they were resolved)

- Results of verifying the accuracy of Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) (i.e., were any issues identified when verifying TINs/NPIs? If so, please provide details and examples regarding the identified issues and how they were resolved)

19

Data Validation Execution Report (cont.)

- Results of verifying that 2020 MIPS Quality Measure specifications and/or QCDR measure (QCDR only) specifications are utilized for submission (i.e., were any issues identified when verifying that only 2020 MIPS Clinical Quality Measures and/or QCDR measures (as applicable) were submitted? If so, please provide details and examples regarding the identified issues and how they were resolved)

- Results of calculating data completeness and performance rates (i.e., were any issues identified with how the MIPS quality measure specifications and/or QCDR measure specifications (as applicable) were implemented in the system? If so, please provide details and examples regarding the identified issues and how they were resolved)

- Results of the randomized audit (i.e., were there any data issues identified? If so, please provide details and examples regarding the identified issues)

- Results of the detailed audit (i.e., provide details and examples regarding how the identified data issues were resolved (Note: The detailed audit is required if errors are found through the randomized audit)

20

Data Inaccuracies

• Data inaccuracies that affect MIPS eligible clinicians may result in:- Remedial action may be taken against your QCDR or Qualified Registry due to

the low data quality rating.

- Will have the QCDR or Qualified Registry Qualified Posting updated for the performance period of MIPS to indicate the QCDR’s or Qualified Registry’s data error rate on the CMS website until the data error rate falls below 3 percent and that remedial action has been taken against the QCDR or Qualified Registry.

• Data inaccuracies affecting more than 5 percent of your total MIPS eligible clinicians may lead to termination of the QCDR or Qualified Registry for future program year(s).

• CMS will evaluate each quality measure for data completeness and accuracy. The vendor will also attest that the data (quality measures, improvement activities, and Promoting Interoperability objectives and measures) results submitted are true, accurate, and complete to the best of their knowledge.

21

Data Inaccuracies (cont.)

• CMS will determine error rates calculated on data submitted to CMS for MIPS eligible clinicians.

• CMS will evaluate data inaccuracies including, but not limited to: - TIN/NPI Issues – Incorrect Tax Identification Numbers (TINs), incorrect National

Provider Identifiers (NPIs), submission of group NPIs

- Formatting Issues – Submitting files with incorrect file formats, submitting files with incorrect element formats, failure to update and resubmit rejected files

- Calculation Issues – Incorrect qualities for measure elements, performance rates, and/or data completeness rates; numerators larger than denominators

- Data Audit Discrepancies – Since data audits are required to occur prior to data submission, QCDRs and Qualified Registries should correct all identified errors prior to submitting the data to CMS. QCDR and Qualified Registry acknowledgement of data discrepancies found post submission from clinician feedback reports.

22

Remedial Action

• CMS may take remedial action for failing to meet applicable criteria for approval or submit data that is inaccurate, unusable, or otherwise compromised.

• Failure to comply with the remedial action process may lead to termination of third-party intermediaries for the current and/or subsequent performance year.

23

Remedial Action (cont.)

• If remedial action is applied, CMS will require that the QCDR or Qualified Registry take internal remedial action by submitting a corrective action plan to address any deficiencies or issues and prevent them from recurring.

• The corrective action plan must be received by CMS within 14 calendar days from the date of the CMS remedial action notification for CMS review and approval.

• Failure to comply with the remedial action process may lead to termination of third-party intermediaries for the current and/or subsequent performance year.

QCDR Name Contact Information Website Cost

**CMS has taken Remedial Action against this QCDR for 2019**ABC QCDR

ABC QCDR Contact Information

ABC QCDR Website

Annual subscription of up to $500 per clinician

**Terminated: No longer a 2019 QCDR Vendor**XYZ QCDR

XYZ QCDR Contact Information

XYZ QCDR Website

Annual subscription of up to $500 per clinician

SELF-NOMINATION DEMONSTRATIONAnastasia Robben, MIPS QCDR/Registry Support Team (PIMMS Team)

24

QCDR MEASURE SUBMISSION TEMPLATEINFORMATIONJocelyn Meyer, MIPS QCDR/Registry Support Team (PIMMS Team)

25

26

QCDR Measure Submission Template

QCDRs submitting QCDR measures will need to submit their QCDR measures for consideration using the 2020 QCDR Measure Submission Template.

The following suggestions should be considered prior to submitting your QCDR measure submission template:

• Documentation of permission to use a QCDR measure must be obtained prior to submission of your QCDR measure submission template containing the QCDR measure or if included without permission, the QCDR measure status must show to be a “work in progress” and not “Ready for PIMMS review” until documentation of permission is obtained.

• Only limited information required in the template for a “borrowed” QCDR measure. (See QCDR measure submission template instructions.) The final QCDR measure owner specifications will be inserted by the QCDR support team.

• Previously approved QCDR measures can be withdrawn from consideration by updating the QCDR measure status to “Withdrawn.”

27

QCDR Measure Submission Template (cont.)

• Pre-filled templates will contain blanks for columns new to the 2020 template and/or may contain errors. Perform internal Quality Assurance as you review your QCDR measures.

• Verify that standardized language (drop-down selections) were used in the appropriate columns.

• If QCDR measure has a change that does not impact the intent of the measure, it is still important to note that change to aid in review.

• Verify the meaningful measure area selected meets the intent of that area as applied to your QCDR measure.

• Verify measure analytics can be correctly applied to the QCDR measure.

• “QCDR Notes” column to be used to communicate any pertinent information you feel did not have another place to document (e.g. notes about harmonization efforts).

• Perform spelling and grammar checks and correct identified items.

QCDR MEASURE SUBMISSION TEMPLATE DEMONSTRATIONJocelyn Meyer, MIPS QCDR/Registry Support Team (PIMMS Team)

28

RESOURCES & WHO TO CALL FOR HELPHector Cariello, MIPS QCDR/Registry Support Team (PIMMS Team)

29

Resources

• Quality Payment Program Website

• QPP Participation Status Tool

• MIPS Explore Measures Tool

• QPP Resource Library

• QPP Webinar Library

30

• QPP Help and Support Page

• QPP Listserv – available on the Quality Payment Program website

31

Who to Call for Help

For Quality Payment Program support, contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (Monday-Friday 8AM-8PM ET). TTY users can call 1-877-715-6222.

• Please know that important program information regarding a variety of topics may be distributed from the QCDR Vendor Support mailbox (QCDRVendorSupport@GDIT.com) and/or the Qualified Registry Vendor Support mailbox (RegistryVendorSupport@GDIT.com).

• To ensure that inquiries are routed to the appropriate subject matter experts, all inquiries must be submitted through the Quality Payment Program and NOT the QCDR or Qualified Registry Vendor Support mailbox.

Q&A SESSIONCMS Subject Matter Experts and MIPS QCDR/Registry Support Team (PIMMS Team)

32

33

Q&A Session

• To ask a question, please dial:

1-866-452-7887

• If prompted, provide the conference ID: 8589745

• Press *1 to be added to the question queue.

• You may also submit questions via the Q&A box.

• Speakers will answer as many questions as time allows.

• Ask most important questions first.