AMA provides resources to help physicians with MIPS reporting

As part of its effort to improve Medicare Payment Reform, the American Medical Association (AMA) is providing tools for physicians to better understand and meet the reporting requirements under the new Quality Payment Program from CMS. The AMA has created a “One Patient, One Measure, No Penalty” campaign to help physicians understand the reporting requirements and avoid the 4 percent penalty for not reporting under the Merit-Based Incentive Payment System (MIPS) track. Along with this campaign, the AMA has created an interactive MIPS Action Plan that provides deadlines and a step-by-step plan of how to meet the reporting requirement deadlines.

As part of the “One Patient, One Measure, No Penalty” campaign, the AMA has provided a short video that demonstrates how to fill out CMS forms to accurately report a quality measure on a patient encounter. A step-by-step guide is also provided as a supplement to the video, along with a sample form to review. There are also links to other tools, such as the CMS Quality Measure Search tool, so that all of the resources are available in one easy-to-find location.

The MIPS Action Plan is a ten-step plan that begins with a determination of whether MIPS applies to the physician. The AMA provides a detailed breakdown of some of the determining factors, such as whether a physician is considered a hospital-based physician, in a frequently asked questions supplemental resource. The MIPS Action Plan then proceeds to walk through the process of reporting, including deadlines to start reporting, and submitting 2017 MIPS data.

Kusserow on Compliance: EHR incentive program attestation is serious business

The American Recovery and Reinvestment Act of 2009 (ARRA) (P.L. 111-5) authorized providing incentive payments to eligible health care professionals, hospitals, and Medicare Advantage Organizations (“MAOs”) to promote the adoption and “meaningful use” of health information technology and electronic health record (“EHR”) systems. CMS established the Medicare and Medicaid Electronic Health Record Incentive Programs (EHR Incentive Programs) to make incentive payments to health care professionals and providers that meet specified requirements for the meaningful use of certified EHR technology (CEHRT). The EHR Incentive Programs are intended to bring about improved clinical outcomes and population outcomes, increase transparency and efficiency in health care, empower individuals to make decisions regarding their care, and generate additional research data on health systems. Program participants must report on their performance pertaining to certain clinical quality measures (CQMs) and objectives to CMS (for Medicare) or the authorized state agency (for Medicaid) through an attestation process. Since 2011, the EHR Incentive Programs have made incentive payments to numerous eligible professionals, eligible hospitals, and critical access hospitals (CAHs) that qualify as “meaningful users” by meeting the objectives and CQMs outlined in the various stages of the applicable programs.

Annual attestations required

Eligible providers must annually attest to meeting the specified objectives and measures in order to receive incentive payments under the EHR Incentive Programs. Once they have attested to meeting the identified objectives and measures, they are deemed to be meaningful users and eligible for incentive payments.  CMS, its contractor, and state Medicaid agencies conduct both random and targeted audits to detect inaccuracies in eligibility, reporting, and receipt of payment with respect to the EHR Incentive Programs.  Eligible hospitals may be selected for pre- or post-payment audits. CMS has required that eligible hospitals retain all supporting documentation used in completing the Attestation Module responses in either paper or electronic format for six years post-attestation. Eligible hospitals are responsible for maintaining documentation that fully supports the meaningful use and CQM data submitted during attestation. Those hospitals undergoing pre-payment audits will be required to provide supporting documentation to validate submitted attestation data before receiving payment.

Unsupported and false attestations

Making false statements, including attestations to the federal government, could implicate federal law (18 U.S.C. § 1001), which generally prohibits knowingly and willfully making false or fraudulent statements or concealing information. Although eligible hospitals receiving incentive payments under the Medicare and Medicaid EHR Incentive Programs are not required to follow any particular parameters when spending the payments, they must annually attest to meeting the relevant measures and objectives in order to be entitled to incentive payments. It is critical that eligible hospitals maintain documentation that supports their attestations.  Supporting documentation needs to make clear that the hospital is meeting the terms and conditions of the EHR Incentive Program. A checklist document by itself would be insufficient as supporting documentation. Failure to maintain such supporting documentation creates potential liability. Although no significant enforcement activity has taken place, compliance officers are advised to verify that proper supporting documentation is maintained.  In fact, the responsible program manager should be maintaining documentation as part of ongoing monitoring. As part of ongoing auditing, the compliance office should ensure that monitoring is conducted and validate that it is adequately meeting regulatory requirements.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.



Results from patient-centered medical homes study ‘significant’

Little evidence exists supporting the case for patient-centered medical homes (PCMHs), leaving decision-makers’ opinions on their use mixed. A recent study, the paper for which appeared in the March issue of Health Affairs, looked at the findings from 11 major PCMH evaluations in eight states to provide estimates of PCMH impact on utilization, cost and quality. The results were “significant.”

What is a PCMH?

Also referred to as a primary care medical home, advanced primary care, or a healthcare home, the patient-centered medical home model aims to reduce spending and improve quality while emphasizing coordinated, patient-centered care. HHS’ Agency for Healthcare Research and Quality (AHRQ) provides five functions or attributes of a PCMH:

1. Comprehensive care: The PCMH must meet the needs of the large majority of a patient’s physical and mental health needs, i.e., prevention and wellness, acute care, and chronic care.
2. Patient-centered: Health care must be relationship-based with an orientation toward treating the whole person, supporting patients and their families managing and organizing their own care.
3. Coordinated care: Care must be coordinated across the broader health care system, encompassing specialty care, hospitals, home health care, and community services and supports, particularly important during transitions between sites of care.
4. Accessible services: A medical home must deliver shorter wait times for urgent needs, better in-person hours, around-the-clock access (telephone or electronic) access to a care team member, and alternative methods of communication.
5. Quality and safety: Medical homes must show a commitment to quality and quality improvement, use evidence-based medical and clinical decision-support tools to share decision-making with patients and families, engage in performance measurement and improvement, measuring and responding to patient experiences and satisfaction, and practice population health management.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-2) calls for “increased quality, efficiency, and clinical practice metrics that existing models such as the PCMH support,” according to letter to then-Acting Administrator of CMS, Andy Slavitt, when the American Academy of Family Physicians and other organizations requested that CMS affirm PCMHs as an eligible alternative payment model (APM). The study authors point to PCMHs being one of the APMs under MACRA, and specifically that MACRA’s Comprehensive Primary Care Initiative (CPCI) “will become a core feature of the Medicare payment system.”

Findings of the study

The study found that PCMH evaluations varied significantly across the 11 major evaluations studies. PCMH resulted in reduced spending (4.2 percent reduction) and improvements in breast cancer screening rates for high-needs patients (1.4 percent increase), lower use of specialist visits (1.5 percent reduction), and increased cervical screening for all patients (1.2 percent increase). The results of this study, combined with mixed results from earlier studies, the study authors note, show that how a PCMH is implemented is critical to achieving the desired impact on primary care. “PCMH initiatives are not ‘one size fits all.’”

The study authors note that while there are a wide variety of approaches to PCMH implementation today, under the CPCI, practices operating a PCMH will share a single payment models and other standard features, so there will be fewer differences. The study authors noted that “identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.”

Compare websites for IRFs and LTCHs have launched

The quality of patient care that inpatient rehabilitation and long-term care facilities provide to patients can vary greatly from facility to facility. To allow patients, family members, and health care providers to get a snapshot of the quality of care each inpatient rehabilitation facility (IRF) and long-term care hospital (LTCH) facility provides, CMS has announced the launch of the IRF Compare and LTCH Compare websites.

It is hoped that the information on IRF and LTCH Compare will help patients make more informed decisions about where they get their health care and encourage these facilities to improve the quality of care they provide. IRF Compare currently contains data from approximately 87 percent of all IRFs and LTCH Compare contains data from approximately 97 percent of all LTCHs.

Basis for establishment

These Compare websites were created to fulfill the requirements of the LTCH Quality Reporting and the IRF Quality Reporting Programs, which were established by section 3004(a) and (b) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), respectively, and required the Secretary of HHS to establish procedures for making quality data submitted by IRFs and LTCHs available to the public.

Current quality measures

Currently, there are two quality measures that are being displayed on the IRF and LTCH Compare websites: (1) the percent of residents or patients with pressure ulcers that are new or worsened (short stay); and (2) the all-cause unplanned readmission percentage for 30 days post discharge.

IRF data for the percent of residents or patients with new or worsened pressure ulcers was collected and submitted to CMS via the IRF Patient Assessment Instrument. The national measure for new or worsened pressure ulcers in IRFs is 0.8 percent. Data for the all-cause unplanned readmission measure for 30 days post-discharge is based on Medicare fee-for-service claims submitted by IRFs and other hospital providers. The IRF national average for all-cause readmission 30 days post discharge is 13.06 percent.

LTCH data for the percent of residents or patients with new or worsened pressure ulcers was collected and submitted to CMS via the LTCH Continuity Assessment Record & Evaluation Data Set, which is an assessment-based data collection instrument created by CMS. The national measure for new or worsened pressure ulcers is 1.8 percent for LTCHs. Data for the all-cause unplanned readmission measure for 30 days post discharge from LTCHs is based on Medicare fee-for-service claims submitted by LTCH and other hospital providers. The national average for all-cause readmission 30 days post discharge is 24.61 percent for LTCHs.

Healthcare-acquired infections to be added soon

The Centers for Disease Control and Prevention (CDC) is currently making efforts to implement a new national baseline for healthcare-acquired infections (HAIs) that are reported to CMS via the CDC’s National Healthcare Safety Network (NHSN). As such, CMS will wait until spring 2017 to begin publishing HAI data on the IRF and LTCH Compare websites.

Review of data

CMS encourages IRFs and LTCHs to review their data as provided in their preview reports.If they disagree with performance data contained within their preview reports, they have an opportunity to request review of that data by CMS. The process for submitting a request is outlined on CMS’ IRF Quality Public Reporting and LTCH Quality Public Reporting webpages.

Spring 2017 data for IRFs are ready for review

The IRF QRP provider preview reports are now available for review and are scheduled for a spring 2017 posting. IRFs should review their performance data on each quality measure based on Quarter 2-2015 to Quarter 1-2016 data prior to its public display on IRF Compare in the spring of 2017.

IRFs have 30 days (from December 11, 2016 through January 10, 2017) to review their performance data. Corrections to the underlying data will not be permitted during this time; but IRFs may request CMS review of the data contained within their preview report, should they believe it to be inaccurate.