Maximizing Your Potential for Reimbursement Under the Quality Payment Program

It’s midway through the year and practices most likely have selected their quality measures and are collecting data to meet the reporting requirements under CMS’ Quality Payment Program (QPP) under the 2018 Final Rule.

But how do you know your practice is working to maximize your performance? It is all about communication and planning.

Using Your Certified EHR

Practices should have checked before the end of 2017 to see that their electronic health record (EHR) vendor is certified and able to gather data on the measures you chose for your practice, particularly for the Quality, Improvement Activities, and Promoting Interoperability performance categories. At the end of 2018 (or at the end of a 90-day reporting period for promoting interoperability and improvement activities), Merit-based Incentive Payment System (MIPS)—eligible clinicians will extract their data and submit it to CMS.

Because CMS updates clinical quality measures on a yearly basis, EHR vendors have to update their software to meet the requirements of the latest version of each certified measure. For many vendors, these measure updates require time and may not be available at the start of the performance year. The potential lag in updating may make it difficult for practices to review their quality performance to ensure the practice, and eligible clinicians, are gathering and capturing the data correctly for each measure. Correct data will enable you to monitor whether or not you are on track to maximize your payment adjustment on reimbursements. It is important for your practice to maintain communication with the EHR vendor to assure that updates are completed.

Many EHRs will not be able to provide performance-level data with decile scoring, and it may be up to your practice to keep track of the scoring on each measure. Additionally, scoring may vary depending on reporting method, so if your EHR does provide decile scoring, it may differ depending on how you end up submitting the quality data. Working closely with your EHR vendor will be vital to your success in reporting.

Communication Within Your Practice

By following best practices, your eligible clinicians should create a roadmap for quality participation in MIPS—outlining the chosen measures, method of submission (qualified clinical data registries, EHRs, or CMS Web Interface), a defined workflow to gather and document data for each measure and their endpoint or goal. Clinicians should clearly document their roadmap so that all reviewers can clearly understand, interpret and evaluate their results, and how they got there.

What practices may not realize is that each quality performance measure has a different performance requirement to receive the full measure score. For example, one performance measure may only require the practice to achieve a 70% performance rate to achieve a full 10 points, whereas another measure may need an 85% performance rate to score 10 points. Practices should also recognize that this means their goal is not always going to be 100% performance on each of their quality measures. The method of submission chosen by a practice will also impact the required performance rate for each of their measures.

While ensuring that all clinicians are on the same page and understand the end-goal is important, they must also agree on the processes put in place regarding workflow documentation. Data must be uniformly entered in to the EHR to ensure the practice receives the highest MIPS composite score possible. Disparate processes or practitioners who are not entering the data in a similar fashion could mean losing points on measures and therefore, losing Medicare reimbursement money.

It’s highly recommended that practices monitor their numbers on a monthly basis, but no less than on a quarterly basis, to know where deficits may be and to identify areas for improvement. It is necessary to see that all the touchpoints are being captured by everyone in the practice to ensure you are going to meet the measure or see at the very least, a true reflection of the data. Waiting until that last quarter will not allow for adequate course corrections or potential improvements in your scoring.

Communication within the practice is critical to make sure everyone is capturing the data in the same way.

Staying on Top of Your EIDM Account

Clinicians, groups, MIPS, alternate payment models (APMs), and certain advanced APM participants all need an Enterprise Identity Management (EIDM) account to submit data for the QPP. An EIDM account may have been set up if you completed your own 2017 MIPS reporting, or if you had used the account to access feedback reports during the Physician Quality Reporting System and Value Modifier days. It is important that a practice maintain a record of who the main account holder is (security official or individual practitioner) and any affiliated users who have access to your Tax Identifier Number’s EIDM system.

CMS requires a change in passwords at set intervals and users sometimes need to be recertified. Continuing to access the account and examining the 2017 Feedback Report (formerly known as the QRUR), which will be made available this summer, will save the practice time and energy from trying to re-access their account and potentially wait on the QPP help desk line.

There is still time to review your quality measures, communicate within your practice about any missed opportunities or modifications in your workflow processes, and with your EHR vendor to confirm that your documentation for each measure will suffice for accurate calculation and reporting.

The evolution to a high-quality cost-effective model of care will be the standard for reimbursement programs. Understanding how your practice can maximize effectiveness for patient care, with operative workflows and optimal data capture, will help ensure your practice’s financial success.