quality reporting office hours - aqihq.org

aqihq.org

Quality Reporting Office Hours

Annette Antos, AQI Registry Manager

Erika Kalb, AQI Registry Services Associate

Toni Kaye, Quality Program Manager

December 12, 2017

Agenda

QRA Update

2018 MIPS Overview

© 2017 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 2

Agenda

AQI Update

- Provider Consents Update

- 2017 Reconciliations

- Data File Submission Emails

- Updating Provider Lists

- 2017 Reporting Deadlines


MIPS 2018 Changes – Eligibility

- Not first year enrolled in Medicare

- Not significantly participating in Advanced APMs

- Exceeds Low-Volume Threshold – Increase for 2018

- Determine MIPS Eligibility: https://qpp.cms.gov/participation-lookup


2017Bills at least $30,000

Medicare Part B chargesAND sees 100 Medicare Part B patients in a year

2018Bills at least $90,000

Medicare Part B charges AND sees 200 Medicare Part B patients in a year

*Disclaimer: Changes identified in this presentation do not represent all changes made in the Quality Payment Program (QPP) in 2017 to 2018

https://qpp.cms.gov/participation-lookup

MIPS 2018 Changes – Special Status

- Non-patient facing

- Hospital-based

- Small Practice

- Rural Practice

- Health Professional Shortage Area

- Ambulatory Surgical Center-based – NEW in 2018

CMS special status definitions/calculations: https://qpp.cms.gov/participation-lookup/about



https://qpp.cms.gov/participation-lookup/about

MIPS 2018 Changes – Performance Period



2017“Pick Your Pace” options for MIPS Reporting• Full Year: 12 months of data to CMS• Partial Year: 90 days of data to CMS• Test reporting: Submit one measure or Improvement Activity

2018There are no “Pick Your Pace” options in 2018: • Quality: 12 months • Cost: 12 months • Improvement Activities: 90 days• Advancing Care Information: 90 days

MIPS 2018 Changes – Quality Component

- Eligible clinician/group must report six (6) measures including one outcome or high-priority measure if an outcome does not apply

− If fewer than 6 measures apply, the EC/group must report all applicable measures

- Anesthesiology Specialty Measure Set – Measure Added

− MIPS #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)*

- Data Completeness Requirements – Increase for 2018


2017Report at least 50% of

all denominator-eligible cases for each

measure

2018Report at least 60% of

all denominator-eligible cases for each

measure

MIPS 2018 Changes – Cost Component

- MIPS ECs/groups will be evaluated on two cost measures in 2018:

o Medicare Spending per Beneficiary

o Total Per Capita Cost

- Calculated automatically by CMS, using administrative claims data

o If data minimums are not met and no Cost component score can be calculated, Cost component will be reweighted to Quality


2017Weighted at 0% of Total

MIPS Score

2018Weighted at 10% of

Total MIPS Score

MIPS 2018 Changes – Improvement Activities

- ECs/groups must complete activities worth 40 points

- Special reweighting for the following providers:

o Small, rural, HPSA and non patient-facing ECs/groups

- Perform activities for 90 days

- Yes/No attestation through AQI

- Maintain documentation for six years

- Additional activities added for 2018

o AQI NACOR to provide list of supported activities soon


MIPS 2018 Changes – Advancing Care Information

- In 2018, new exemptions were added in addition to the current exemptions (non-patient facing, hospital-based):

o Ambulatory Surgery Center (ASC) based ECs – automatic− Retroactively applied for 2017 performance year

o Small practices (15 or under ECs) – application required− Only applies for 2018 and beyond

- Apply for hardship exemption by December 31:

− https://qpp.cms.gov/mips/advancing-care-information/hardship-exception

- AQI NACOR is not supporting ACI Component in 2018


https://qpp.cms.gov/mips/advancing-care-information/hardship-exception

2018 Performance Threshold and Payment Adjustment


2017• 3 point threshold• Exceptional performer at 70 points• Payment adjustment at +/- 4%

2018• 15 point threshold• Exceptional performer at 70 points• Payment adjustment at +/- 5%

Achieving minimum threshold in 2018

• Submit 5 quality measures that meet data completeness criteria

• Report required Improvement Activities

• Meet ACI base score measures and one Improvement Activity

AQI - Provider Consents Update

- New for 2017 CMS is requiring provider consents to be signed and returned to

AQI prior to submission of data to CMS

o Only applies to those reporting as Individuals – not Group Reporting

o ArborMetrix consent process – Complete!

o Emails were sent to practices beginning November 6th

o Consents will be due by 2/28/18


2017 Reconciliations

- As noted in the NACOR Standard Quality Reporting order form you completed at

enrollment, AQI will soon begin reconciling purchased Eligible Clinician (EC)

counts against actual data submitted.

o AQI will begin sending invoices where applicable in January, and all payments

must be received by March 16, 2018.

- For example, if a practice ordered quality reporting services for 10 CRNAs, but

submitted data for 12 CRNAs, AQI will invoice for two additional CRNAs. If AQI

does not receive payment for the two additional CRNAs by March 16, 2018, the

additional CRNAs’ data will not be submitted to CMS.


Data File Submission Emails

- Autogenerated emails began week of 12/4

−No Data Submitted

−Successful Data File Submission

- Sender will be your AQI Account Manager

- Will be sent bi-monthly to the AQI Champion


Successful Data File


Dear AQI Champion

Our records indicate that Smith Anesthesia – ID 000 recently submitted a data file to AQI’s National Anesthesia Clinical Outcomes Registry (NACOR).

We encourage you to log into the NACOR Dashboard (https://aqi.arbormetrix.com/Registry ) to review your submitted data for completeness and accuracy. To learn how

best to review your dashboard reports, refer to this step-by-step guide.

As a reminder, section 8 of the Addendum for Quality Reporting to the NACOR Participation Agreement states that your practice “and each EC agree, and Participant shall

require each EC, to review his/her measure results in AQI at least four times a year and provide timely feedback to AQI on the measures that will be reported on the EC’s

behalf.”

If you have any questions once you have reviewed the data, please submit a helpdesk ticket to [email protected] .

If you have a general question, please contact your AQI account manager or email [email protected] .

Thank you.

The AQI Team

https://aqi.arbormetrix.com/Registry

https://www.aqihq.org/files/Reviewing your 2017 CMS Quality ReportsDec2017.pdf

mailto:[email protected]

mailto:[email protected]

http://www.aqihq.org/

No Data Submitted


Updating Provider Lists – NACOR Dashboard


Login to the NACOR dashboard

- Under Provider Management, practice

champions are able to:

• Add Providers

• Search Providers

• View practice, provider or facility lists

Practice List: This will display basic practice

Information, AQI Practice champion, QR option.

Provider List: This will display a list of providers that are tied

to your practice. It will include their NPI number, and AQI

Champions will be able to attest to improvement activities here.

Facility List: This will display the list of all the facilities that the providers

Perform anesthesia services at.



Within the Admin Dashboard, under “Provider Management”, select the symbol.

This will prompt the “Add Provider” window

to appear.

• Fill out all of the fields

• Ensure the “Report to CMS for this EP”

selection is “Yes” if you plan to submit their

data to CMS.


- Provider List Audit

• To ensure accuracy, AQI Practice Champions should review provider lists periodically through

out the reporting year.

• Verify each Provider NPI

o The NPI field ties each EC to the practice data that is submitted to CMS. NACOR submits

data according to this list, so accuracy is very important

• Verify accuracy of Billing TINS

• Report to CMS should be set “Yes” to ALL providers that you intend to submit data for.


AQI Deadlines


2017 NACOR Quality Reporting Deadlines12/15/2017 Enrollment in Merging and/or Formatting Services

01/31/2018 January – November 2017 Data Submission

02/15/2018 Enrollment in NACOR Quality Concierge 90 day or 1 measure/1 case option; December 2017 Data Submission; In NACOR Dashboard:

CMS Opt-OutTIN/NPI ReconciliationImprovement Activity Attestation

02/28/2018 Individual Quality Reporting Consent Submission

Next Quality Reporting Office Hours

Tuesday, January 9th

11am CST or 5pm CST

11am: Registration URL:

https://attendee.gotowebinar.com/register/4801735890019659523

5pm: Registration

URL:https://attendee.gotowebinar.com/register/7685839552071660291




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quality reporting office hours - aqihq.org

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