NCQA has recently updated their PCMH 2014 and PCSP 2016 Standards. The updates come out three times per year: March, July and November. While these updates are not drastic, organizations must follow the most current requirements. Therefore it is important to review them each time.
Updated Standards and Guidelines with the Summary of Updates are available below for each program:
PCMH 2014 Standards and Guidelines
PCMH 2014 Summary of Updates
PCSP 2016 Standards and Guidelines
PCSP 2016 Summary of Updates
All updates can be found in the ISS survey tool. If you would like an e-publication you can access an updated one via the NCQA website. If you have previously downloaded an e-publication in the past, you can sign into the Download Center here and access the most updated full publication. If you have never downloaded an e-publication, you can visit the NCQA Store here.
For those who have previously downloaded e-publications from NCQA, an email is sent out notifying you of updates in order to keep you current with the latest version of standards.
Contact the Kentucky REC at 859-323-3090 with your questions about PCMH and PCSP. We’re here to help.
Looking forward to a happy and productive 2017.
Your friends at Kentucky Regional Extension Center.
December 31, 2016: Reporting for the 2016 PQRS program year ends for both group practices and individuals (Note: 2016 program year data will determine the 2018 payment adjustment)
January 1, 2017: Payment adjustments begin for both group practices and individuals who did not satisfactorily report quality data to CMS in 2015
January 1, 2017: First day to submit 2016 PQRS data using registry, EHR, or QCDR
January – March 2017: 2016 GPRO Web Interface submission will be in the first quarter; stay tuned for exact dates
February 24, 2017: Last day 2016 claims will be processed to be counted for PQRS reporting to determine the 2018 payment adjustment
February 28, 2017: Last day to submit 2016 CQMs for dual participation in PQRS and the Medicare EHR Incentive Program
February 28, 2017: Last day for QCDRs (QRDA) and EHRs to submit 2016 data
January 1, 2018: Payment adjustments begin for both group practices and individuals who did not satisfactorily report quality data to CMS in 2016
January 1, 2018: Last day for 2016 QCDRs (XML only) and registries to submit 2016 data
Here is the complete CMS timeline.
If you have questions or need help, call the Kentucky REC for additional information: 859-323-3090
On October 14, 2016, CMS released its final rule for the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act (MACRA). Federally Qualified Health Centers and Rural Health Centers have asked if MACRA applies to them. The answer is a bit complicated.
The MACRA Final Rule makes clear that FQHC and RHC services billed under the global or all-inclusive rate are not subject to the Merit-Based Incentive Payment System (MIPS) payment adjustments. (See below.) Many FQHCs and RHCs do bill some services such as lab and portions of radiology services under Medicare Part B. Because of this, some have received penalty notices for not participating in PQRS, and therefore, they are worried they will continue to get penalties under MACRA and MIPS. The good news is that, unlike PQRS, MACRA has a low volume exclusion that may exempt those FQHCs and RHCs from MIPS payment adjustments for their Medicare Part B payments. CMS does encourage FQHCs and RHCs to participate voluntarily, if they desire to do so.
From page 46 of the MACRA Final Rule pdf in the Federal Register (or page 77053):
…Services rendered by an eligible clinician under the RHC or FQHC methodology will not be subject to the MIPS payments adjustments. However, these eligible clinicians have the option to voluntarily report on applicable measures and activities for MIPS, in which the data received, will not be used to assess their performance for the purpose of the MIPS payment adjustment.
Decision Tree Analysis
If an FQHC or RHC bills Medicare Part B for some services, it may be subject to MACRA’s provisions, however. For instance, RHCs must look at how much traditional Medicare Part B is billed using a 1500 claim form (versus the all-inclusive rate). FQHCs must look at whether they bill Medicare Part B for some office procedure components, such as EKGs, pulmonary function tests, Holter monitors and some radiology services. So, how does an FQHC or RHC decide what to do? Please consider the following questions in deciding what course is best for your FQHC or RHC:
1. How much do you bill Medicare Part B in a year? Could you be exempt due to a low volume threshold?
– If less than $30K or 100 pts for the whole group/tax payer ID (TIN), then no MIPS participation required. RHC or FQHC as a group meets low volume exemption.
– If more than $30K or 100 patients, go to question 2.
2. Could the Medicare low volume threshold apply to your individual clinicians?
– Is it possible that individual clinicians meet the low volume threshold and will be exempt from MIPS? Be sure to exclude non-patient facing and first year providers for calculations as they are exempt from MIPS.
– Example: Seven eligible clinicians in an FQHC are a part of the same TIN and each bills less than $10,000 in Medicare Part B charges. The group together exceeds the low volume threshold. However, CMS will also look at individual clinician billing and so they will likely be excluded.
3. If the FQHC or RHC’s clinicians are not exempt from MIPS, then consider: will the 4% penalty for non-participation in the first year harm your financial health? Or will paying staff or IT costs needed for MIPS be worth it to avoid the penalty? If the revenue is substantial and patients like the convenience of labs, radiology and other services being performed on site, it may be worth it to participate in MIPS.
4. When in doubt, consider using Option 1 in 2017: report something under MIPS. CMS has made it extremely easy to report and avoid penalties in the first year.
Who determines which groups or clinicians meet the low volume exclusion?
CMS will review Part B claims and make a determination whether groups and individual clinicians are excluded due to low volume. CMS intends to provide a NPI level lookup feature that will allow clinicians to know whether they are excluded from MIPS. For more information, see the Low Volume Threshold section of the Final Rule beginning on page 220 for more information.
What if RHCs or FQHCs are in APMs?
Certain FQHCs or RHCs may have “qualifying providers” (QPs) in advanced Alternative Payment Models (APMs) such as a Medicare Shared Savings Program Track 2 or Track 3 Accountable Care Organizations. These QPs may be eligible for additional bonuses under MACRA. For more information, see the following sections from page 451 of the pdf or page 77458 of the Federal Register version of the MACRA Final Rule:
CMS proposed that beneficiaries in RHCs and FQHCs that participate in ACOs, and that are reimbursed under the RHC AIR or FQHC PPS be counted towards the QP determination calculations under the patient count method but not under the payment amount method…Beneficiary will be included in the numerator of the Threshold Score for the patient count method if the beneficiary receives…professional services furnished by eligible clinicians in an Advanced APM Entity at RHCs and FQHCs.
More questions? Contact UK’s Kentucky REC at 859-323-3090.
On October 14, 2016, CMS released its final rule for the Quality Payment Program (QPP) authorized by the Medicare Access and CHIP Reauthorization Act (MACRA).
Kentucky REC presented a MACRA Final Rule Overview webinar to help organization’s understand how this will impact the way they deliver care.
To listen to the webinar, please click here.
The follow questions were asked on the webinar. We have answered the Frequently Asked Questions below:
1. Does MACRA/MIPS affect Medicaid clinicians? I do not participate in Medicare, only in Medicaid.
No, MACRA/MIPS only impacts providers who bill Medicare Part B at this time. However, similar changes to value-based payment are expected.
2. What if your RHC is a part of an ACO?
RHCs and FQHCs must first determine eligibility dependent upon whether or not the RHC/FQHC bills at least $30,000 in Medicare Part B and/or bills for 100 Medicare patients (dependent upon whether you are reporting as an individual or group). If the RHC/FQHC is determined to be eligible, then you must determine whether or not your ACO is considered an Advanced Alternative Payment Model (APM) or a MIPS APM. If 20-25% of your Medicare Part B billing is through an Advanced APM, then RHCs or FQHCs may qualify for a 5% lump sum bonus.
3. Can you report on any 90-day period for Advancing Care Information?
Yes, you can report any consecutive 90 day period between January 1, 2017 and December 31, 2017. We recommend that you find your best 90 day period and report on that timeframe before March 31, 2018.
4. Under Advancing Care Information some objectives are eligible for a percentage bonus. Can you receive multiple bonuses for this category?
Yes, you can report multiple objectives to receive bonus points. Each objective has a set percentage of bonus associated with reporting.
5. If a provider get a penalty’s for 2017+ and s/he moves to a different organization will that penalty follow the provider?
Yes. Just like other quality programs, the penalties/incentives follow the provider.
6. Will we still have to do Medicaid MU for individual providers?
Yes, if you want to continue receiving an incentive for the Medicaid EHR Incentive Program, you will need to continue to attest under the guidelines of the Kentucky Department of Medicaid Services. The Medicaid EHR Incentive Program is funded through 2021.
7. Will all of those penalties be stacked for each year?
No. The penalties are only associated with the performance year in which they were incurred.
8. Where do I find information about Patient Centered Medical Home and Patient Centered Specialty Practice Recognition?
You can visit Kentucky REC’s website at www.KentuckyREC.com or you can contact us at 859-323-3090 or firstname.lastname@example.org for information related to Patient Centered Medical Home or Patient Centered Specialty Practice Programs. Kentucky REC has certified content experts on staff to help your practice achieve recognition.
9. Are CPOE and CDS still required for 2016 MU reporting for physician offices?
Yes. Changes to CPOE and CDS rules will impact 2017 Meaningful Use.
10. For the Meaningful Use program there was a very detailed document on the CMS website detailing what each measure required. Is there something similar that talks about each measure/requirement in detail for MIPS?
Yes. Visit CMS’s new Quality Payment Program website at www.CMS.QPP.gov.
11. Is full year reporting required for MIPS?
Each performance category has a required reporting timeframe that is dependent upon the performance year. Therefore, for 2017, you have 4 options available to you which will determine the reporting timeframes for each performance category. Visit QPP website for further details.
12. Can you report quality as a group as with PQRS or is everything reported by individual provider?
Each performance category can be reported as a group/TIN or as an individual EC /NPI.
13. Do I need to sign-up for this program?
No, technically there is no registration required. However, registration may be required for certain methods of submission (i.e. GPRO or CMS Web Interface). It is important to keep your PECOS up to date as well.
14. This system does not seem to empower providers to tackle the larger issues that accompany patients of low income/low education.
The QPP program is intended to improve quality and reduce avoidable cost for all patients. For many clinicians value-based and alternative payment models incentivize them to provide additional support for vulnerable and high-risk patients.
15. Can you explain the extra credit for the Improvement Activities?
Certain Improvement Activities which are identified in the list found on CMS’s website can be submitted/performed using your Certified Electronic Health Record (CEHRT) and these activities can qualify you for bonus points.
16. What ACO organizations are there in this area?
There are many to choose from. Visit www.innovation.cms.gov for a map of the APMs in Kentucky. The QPP site also has a list of available APMs.