Quality Reporting Office Hours
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1 Quality Reporting Office Hours Annette Antos, AQI Registry Manager Erika Kalb, AQI Registry Services Associate Toni Kaye, Quality Program Manager December 12, 2017 aqihq.org
2 Agenda QRA Update 2018 MIPS Overview 2017 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 2
3 Agenda AQI Update - Provider Consents Update Reconciliations - Data File Submission s - Updating Provider Lists Reporting Deadlines 2017 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 3
4 MIPS 2018 Changes Eligibility - Not first year enrolled in Medicare - Not significantly participating in Advanced APMs - Exceeds Low-Volume Threshold Increase for Bills at least $30,000 Medicare Part B charges AND sees 100 Medicare Part B patients in a year 2018 Bills at least $90,000 Medicare Part B charges AND sees 200 Medicare Part B patients in a year - Determine MIPS Eligibility: *Disclaimer: Changes identified in this presentation do not represent all changes made in the Quality Payment Program (QPP) in 2017 to AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 4
5 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: *Disclaimer: Changes identified in this presentation do not represent all changes made in the Quality Payment Program (QPP) in 2017 to AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 5
6 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 2018 There are no Pick Your Pace options in 2018: Quality: 12 months Cost: 12 months Improvement Activities: 90 days Advancing Care Information: 90 days *Disclaimer: Changes identified in this presentation do not represent all changes made in the Quality Payment Program (QPP) in 2017 to AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 6
7 MIPS 2018 Changes Quality Component - Eligible clinician/group must report six (6) measures including one outcome or highpriority 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 Report at least 50% of all denominatoreligible cases for each measure 2018 Report at least 60% of all denominatoreligible cases for each measure 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 7
8 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 2017 Weighted at 0% of Total MIPS Score 2018 Weighted at 10% of Total MIPS Score 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 8
9 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 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 9
10 MIPS 2018 Changes Advancing Care Information - In 2018, new exemptions were added in addition to the current exemptions (nonpatient 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: - AQI NACOR is not supporting ACI Component in AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 10
11 2018 Performance Threshold and Payment Adjustment point threshold Exceptional performer at 70 points Payment adjustment at +/- 4% Achieving minimum threshold in 2018 Submit 5 quality measures that meet data completeness criteria Report required Improvement Activities point threshold Exceptional performer at 70 points Payment adjustment at +/- 5% Meet ACI base score measures and one Improvement Activity 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 11
12 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 s were sent to practices beginning November 6 th o Consents will be due by 2/28/ AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 12
13 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, 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 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 13
14 Data File Submission s - Autogenerated s 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 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 14
15 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 ( ) 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 nacorsupport@arbormetrix.com. If you have a general question, please contact your AQI account manager or askaqi@asahq.org. Thank you. The AQI Team 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 15
16 No Data Submitted 2014 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 16
17 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 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 17
18 Updating Provider Lists NACOR Dashboard 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 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 18
19 Updating Provider Lists NACOR Dashboard - 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 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 19
20 AQI Deadlines 2017 NACOR Quality Reporting Deadlines 12/15/2017 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-Out TIN/NPI Reconciliation Improvement Activity Attestation 02/28/2018 Individual Quality Reporting Consent Submission 2016 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 20
21 Next Quality Reporting Office Hours Tuesday, January 9th 11am CST or 5pm CST 11am: Registration URL: 5pm: Registration URL: AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 21
22 Q&A 2014 AMERICAN SOCIETY OF ANESTHESIOLOGISTS. 22
Quality Reporting Office Hours
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