Hello, and thank you for joining today's 2018 QCDR and Qualified Registry QPP Self-Nomination
Process for Vendors.
Today, representatives from the Centers for Medicare & Medicaid Services will provide
an overview on the Qualified Clinical Data Registry and the self-nomination process for
vendors.
During the webinar, there will be a demonstration on how to complete the 2018 JIRA self-nomination
forms, as well as resources and where to find additional assistance.
You can listen to the presentation through your computer speakers.
If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com.
Questions will be taken via the question box only.
Subject-matter experts will address any questions as time permits.
Any questions not answered on the phone will be directed to QPP@cms.hhs.gov.
I would now like to introduce Dr. Daniel Green, Medical Officer at CMS and the Quality Measurement
and Health Assessment Group working at PQRS.
Dr. Green, you may now begin.
Hi, everybody.
Thank you.
Hi, everybody.
Thank you all for dialing in to today's call.
We are excited that we have several hundred folks on the call, in fact, that are interested
in the Quality Payment Program and potentially interested in becoming one of our qualified
registries or qualified clinical data registries.
So, we have a decent agenda for you guys today to give you a bit of an overview, let you
know kind of the process that we go through and the requirements.
At the end, when we do take the question and answer session, if you could try to restrict
your questions to registry/QCDR as it relates to the QPP, that would be helpful.
If you have other questions, again, we can forward them to our QPP -- Quality Payment
Program -- questions center, and they will respond to you.
Also wanted to let folks know in the next day either by the close of business tomorrow
or on Friday we will be posting our self-nomination documents, which will provide additional information
about requirements, et cetera.
So, please do be on the lookout for that.
We will be sending out a listserv and/or an e-mail to folks that are participating on
today's call to give you the link once we have it posted.
So, again, thank you.
I'll say buckle up, and we're glad you could join us.
We can start the presentation, I guess.
Hector?
Okay.
Thank you, Dr. Green.
So, what we'll be going over today will be the Qualified Registry overview, the Qualified
Clinical Data Registry overview, provide some information in terms of the QCDR measure harmonization
process, the data validation plan requirements, information around the business associate
agreement, resources and who to contact for assistance, and then we'll also do a walkthrough
of the self-nomination form for the 2018 program year.
And then we'll wrap up with some questions and answers session at the end.
Next slide, please.
So, what is a qualified registry?
A qualified registry is an entity that collects clinical data from an individual MIPS-eligible
clinician, group, or virtual group, and submits it to CMS on their behalf.
Clinicians work directly with their chosen registry to submit data on the selected measures
or specialty set measures.
Virtual groups are combination of two or more TINs composed of a solo eligible clinician
or a group of 10 or fewer eligible clinicians that elects to form a virtual group with at
least one other solo practitioner group.
All MIPS-eligible clinicians within a TIN must participate in the virtual group.
We'd also like to note that the virtual group's reporting option reflects what is proposed
in the calendar year 2018 Quality Payment Program proposed rule, and the reporting options
are subject to change based on what is finalized in the calendar year 2018 Quality Payment
Program final rule.
Next slide.
So, what are some of the requirements for a qualified registry?
The first one is, you must have at least 25 participants by January 1, 2018.
These participants do not need to use the qualified registry to report MIPS data to
CMS, but they must submit data to the qualified registry for quality improvement.
You must also provide a statement during the data submission period verifying that all
the data, such as quality measures, improvement activities, and advancing care information
measures and objectives, if applicable, and results are accurate and complete.
You must also submit data via a CMS-specified secure method for data submission, such as
a defined Quality Payment Program data format, such as JSON or XML, and additional information
regarding data submission methodologies can be found in the developer tools section of
the resources section of the Quality Payment Program website.
And you see the link on the screen.
You must also provide information on your process for data validation for both individual
MIPS-eligible clinicians, groups, and virtual groups within a data validation plan.
And results of the executed data validation plan must be provided by May 31st of the year
following the performance period.
Next slide.
A qualified registry must also perform some functions related to data submissions.
The first is that it should indicate the certified EHR technology data source, end-to-end electronic
reporting, if applicable, performance period start and end dates, whether you are reporting
on advancing care information measures and objectives, and whether you are reporting
on improvement activities.
A qualified registry must also submit data and results for all the MIPS performance categories,
and this includes all-payer data, not just Medicare Part B patients, results for at least
six quality measures with at least one outcome measure -- if an outcome measure is not available,
use at least one other high-priority measure -- Quality Measure ID numbers for quality
measures, measure-level reporting rates by TIN/NPI and/or TIN, measure-level performance
rates by TIN/NPI and/or TIN, risk adjusted results for any risk adjusted measures, sampling
methodology of data validation, performance categories feedback at least four times a
year for all individual MIPS-eligible clinicians.
Next slide.
Three -- report on the number of eligible instances or report the denominator, times
a quality service is performed, which would be the performance numerator, times the applicable
submission criteria were not met, and performance exclusions, meaning denominator exceptions
or exclusions.
Qualified registries must also verify and maintain eligible clinician information, and
that is signed verification of clinician names, contact information, costs charged to clinicians,
services provided, measures and specialty-specific measure sets, if appliable, business agreements
with clinicians or groups who provide patient-specific data.
This is to ensure the business associate agreement complies with HIPAA privacy and Security Rules
-- and include disclosure of quality measure results and data on Medicare and non-Medicare
beneficiaries -- again, all-payer information.
Also have signed NPI-holder authorization to submit results and data to CMS for MIPS,
and release all e-mail address for feedback report distribution.
Attestations that all data and results are accurate and complete must also be done.
Five -- comply with any CMS request to review your submitted data, requirements to participate
in the mandatory kick-off meeting and monthly support calls, and also CMS-approved secure
method for data submission.
Again, either an XML or a JSON file are examples of those.
Next slide.
If any data inaccuracies affect more than three percent of your total MIPS-eligible
clinicians, you will be placed on probation due to your low data-quality rating, and the
qualified registry posting will be updated for the
performance period to indicate you are on probation.
Data inaccuracies affecting more than five percent of your total MIPS-eligible clinicians
may lead to being precluded from participating in the following year.
Next slide.
Qualified registries, regardless of prior participation as a registry, must self-nominate
on an annual basis to participate in future program years of MIPS.
Having previously qualified as a qualified registry does not automatically qualify the
entity to participate in subsequent MIPS performance periods.
For the 2018 performance period, CMS has established the self-nomination period from September
1st through November 1, 2017, at 5:00 p.m. Eastern.
Please review the calendar year 2018 Quality Payment Program proposed and final rules for
more information regarding requirements to be a qualified registry in the 2018 MIPS performing
period.
You may also visit the resources library of the Quality Payment Program website for additional
information when available about registry participation for the 2018 MIPS performance
period.
Next slide.
Next slide, please.
So, what is a Qualified Clinical Data Registry?
A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for
data submission.
Examples include, but are not limited to, regional collaboratives and specialty societies.
QCDR reporting is different from qualified registry reporting because QCDRs are not limited
to measures within the Quality Payment Program.
A QCDR may submit a maximum of 30 QCDR measures, formerly known as non-MIPS measures, for review
and approval by CMS for reporting.
QCDRs cannot be owned or managed by an individual or locally owned speciality group.
Next slide.
The requirements for a QCDR are similar to the registry.
You must have at least 25 participants by January 2018, and, again, these participants
do not need to use the QCDR to report MIPS data to CMS, but must submit data to the QCDR
for quality improvement.
You must also provide a statement during the data submission period verifying that all
the data and results are accurate and complete.
For data submission, you must also submit data via a CMS-specified secure method of
data, such as a Quality Reporting Document Architecture, or QRDA III, or Quality Payment
Program data format, such as JSON or XML.
Additional information, again, can be found on the developer tools section of the resource
library on the Quality Payment website.
And you must also provide information on your process for data validation for both individual
MIPS-eligible clinicians, groups, and virtual groups within a data validation plan.
Results of the executed data validation plan must be provided by May 31st of the year following
the performance period.
Next slide, please.
QCDRs also have functions related to submitting data, and they also are similar to the registry,
but they differ slightly.
So, first, they must indicate Certified Electronic Health Record Technology data source, end-to-end
electronic reporting if applicable, performance period start and end dates, whether you are
reporting on Advancing Care information measures and objectives, and whether you're reporting
on Improvement Activities.
Second, submit data and results for all MIPS performance categories, again, including all
payer data, not just Medicare Part B patients.
Submit results for at least six quality measures, including one outcome measure.
And if outcome measure is not available, use at least one other high-priority measure.
And you must also give the entire distribution of measure results
by decile, if available.
Quality measure ID numbers for quality measures.
Provide measure-level reporting rates for TIN/NPI and/or TIN.
Provide measure-level performance rates by TIN/NPI and/or TIN.
Provide performance category feedback at least four times a year for all MIPS-eligible clinicians.
Provide the sampling methodology for data validation, risk-adjusted results for any
risk-adjusted measures, and any additional details for QCDR measures, such as data elements
and measure specifications, risk-adjusted results for QCDR quality data, comparison
of quality of care by measure, by clinician, or group, data from before the start of the
performance period, if available, also all Quality Payment Program and QCDR measures
to CMS on a designated public website.
Provide CMS with the measure specifications, posts, and links via a JIRA comment in your
approved self-nomination form.
And this should include the specifications for your QCDR measures.
Next slide.
You must also report on the number of eligible instances, such as the denominator, times
a quality service is performed, the performance numerator, times the applicable submission
criteria were not met, performance exclusions, and approved QCDR measures.
Again, just as a reminder, QCDRs may submit up to 30 QCDR measures for CMS review and
approval during the self-nomination period if desired.
You must verify and maintain eligible clinician information, such as signed verification of
clinician names, contact information, services provided, costs charged to clinicians, measures,
and specialty-specific measure sets, if applicable, business agreements with clinicians or groups
who provide patient-specific data, and you must ensure that the business associate agreement
complies with HIPAA Privacy and Security Rules.
You also want to include disclosure of quality measure results of data on Medicare and non-Medicare
beneficiaries.
Signed NPI-holder authorization to submit results and data to CMS for MIPS and release
e-mail address for feedback report distribution, also attestation that all data and results
are accurate and complete.
You must also comply with any CMS request to review your submitted data.
It is also a requirement to participate in mandatory QCDR kick-off meeting and monthly
support calls.
And a CMS-approved secure method for data submission must be used, such as an XML file.
Next slide.
For QCDR submission, similar to the qualified registry, if any data inaccuracies affect
more than three percent of your total MIPS-eligible clinicians, you will be placed on probation
due to your low-quality data rating.
The QCDR qualified posting will be updated for the performance period to indicate that
you are on probation.
And data inaccuracies affecting more than five percent of your total MIPS-eligible clinicians
may lead to being precluded from participating in the following year.
Next slide.
For self-nomination, similar to the qualified registries, QCDRs, regardless of prior participation
as a QCDR, must self-nomination to participate in future program years.
Having qualified as a QCDR, again, does not automatically qualify the entity to participate
in subsequent MIPS performance periods.
And for the 2018 performance period, the self-nomination period starts September 1st, which is this
Friday, and goes through November 1, 2017, at 5:00 p.m. Eastern.
Please review the calendar year 2018 Quality Payment Program proposed and final rules for
more information regarding requirements to be a QCDR in the 2018 MIPS performance period.
As a reminder, as well, visit the resources library for the Quality Payment Program website
for additional information when available about QCDR participation for the 2018 MIPS
performance period.
Next slide.
In term of harmonization for QCDR measures, proposed QCDR measures that are similar will
be requested to be harmonized.
The reason for this is that measure harmonization between QCDRs provides eligible clinicians
a bigger cohort for performance scoring and benchmarking.
Collaboration between QCDRs with similar measures is encouraged.
And QCDRs must decide who or which QCDR would retain the measure as the measure owner and
perform the required measure maintenance as needed.
Please note that harmonized measures must be updated to align with the measure owner's
measure specifications for each performance period.
In addition, permission to use another QCDR's measure should be obtained by the time a QCDR
self-nominates for each performance period.
This information should be submitted and uploaded through JIRA at the time of your self-nomination
so that the PIMMS team, as well as CMS, can have that information available during the
QCDR measure review.
Next slide.
For data validation plan requirements, vendors must provide information on their process
for data validation for individual MIPS-eligible clinicians, groups, and virtual groups within
a data validation plan.
Results of the executed data validation plan must be provided by May 31 of the year following
the performance period.
The following must be provided to fulfill the requirements of the Data Validation Plan
-- vendor name, benchmarking capability -- for QCDRs only -- process of verifying Quality
Payment Program eligibility of MIPS-eligible clinicians, groups, and virtual groups, process
of verifying accuracy of TIN/NPI, process of calculating reporting and performance rates,
process of verifying 2018 QPP or QCDR measures utilized for submissions, process used for
completion of randomized audit, and process used for completion of detailed audit.
Please note that the randomized audit and detailed audit should not be the same.
Next slide, please.
In terms of business associate agreement, you may enter into and maintain with your
participating MIPS eligible clinicians an appropriate Business Associate agreement that
provides for the qualified registries or QCDRs receipt of patient-specific data from an individual
MIPS-eligible clinician, group, or virtual group, as well as the qualified registries
or QCDR's disclosure of quality measure results and numerator and denominator data and/or
patient-specific data on Medicare and non-Medicare beneficiaries on behalf of MIPS-eligible clinicians,
groups, or virtual groups.
Next slide.
On this screen, you'll see some resources that are available.
As mentioned throughout the presentation, you may always refer to the Quality Payment
Program website, which is qpp.cms.gov.
You may also refer to the Federal Register or the rule for the program.
The Quality Payment Program listserv -- we encourage you to sign up for the listserv
if you're currently not signed up.
And this will ensure that you do receive communication regarding program updates.
And also the qualified registry and QCDR support calls -- these are for approved vendors only.
And the support calls will be held, again, approximately once per month for approved
vendors.
The support calls address reporting requirements, steps for successful submission, and they
also include a question and answer session.
Attendance to all support calls is mandatory and is a requirement
of participation.
Next slide.
For assistance, you can contact the Quality Payment Program and Merit-based Incentive
Payment System Support team at the Quality Payment Program Service Center.
On the screen, you'll see their phone number and e-mail address listed.
Next slide.
And next slide, please.
And we'll now proceed with the demonstration of the 2018 JIRA self-nomination form.
Okay, can everyone see my screen?
If I hear silence, that means yes.
All right.
So, if you're new to the program and you have not already done so, we suggest getting a
JIRA account.
And you would come to the ONC JIRA main page, and you would click here to sign up for an
account.
And you would complete this information here, and following that, you'd be able to sign
up for an account.
It's really fast and easy to do.
So, once you do that, you can come into the main log-in page and log in to JIRA.
Once you do that, you'll want to go to the Projects tab on the page and select the 2018
QPP self-nomination form Project, and it'll take you to this page.
And what you'll want to do next is select Create to start your self-nomination form.
Just as a reminder also, self-nomination forms should be submitted without waiting for the
calendar year 2018 Quality Payment Program final rule to be published, as you will be
able to provide updates once they are submitted.
One thing that we've also implemented this year is, if you submit your 2018 self-nomination
form to CMS, prior to the close of the self-nomination period -- so, prior to November 1st at 5:00
p.m. Eastern -- and your application is ready for review, we ask that you please notify
the PIMMS team by e-mailing us at qcdrvendorsupport@gdit.com if you're a QCDR or registry registryvendorsupport@gdit.com
if for registries.
Please make sure to include your 2018 self-nomination form JIRA ticket when you do, though, and
that information is provided once you submit the ticket, as well.
Also, when you come to this page, you'll want to make sure that you select the correct issue
type from the drop-down.
So, again, if you're a registry, select the registry option, and if you're a QCDR, make
sure that you select the QCDR.
We've had some instances where last year we had some organizations submit as a registry
when they were intending to submit as a QCDR and vice versa.
You'll also see the different tabs on the self-nomination form.
So, the Field tab provides background information about the self-nomination process, deadlines,
and requirements.
The 2018 Registry or QCDR Self-Nomination tab allows vendors to provid required information
regarding their demographics and contact information, data collection methods, indicate reporting
options, performance categories, and services reported.
And I'll go through a QCDR self-nomination form so you can see it after I give an overview
of the different tabs.
The Individual Measures tab allows vendors to select the individual measures supported
by their organization for the 2018 performance period.
And also just to note again that the list of quality measures below reflects what is
proposed in the calendar year 2018 Quality Payment Program proposed rule.
Measure availability is subject to change based on what is finalized in the calendar
year 2018 Quality Payment Program final rule.
The QPP eCQMs tab also allows vendors to select the eCQMs that will be supported by their
organization for the 2018 performance period.
The Data Validation tab allows vendors to specify the methodology that will be used
for validating the data submitted for the 2018 performance period.
And you must also use the Uploads tab.
The Uploads tab allows vendors to upload their benchmarking methodology, QCDR measures, and/or
data validation plan.
If vendors decide to upload their QCDR measures, we're asking that you please utilize the QCDR
measure submission template, which will be posted soon and will be provided, as well.
The only difference between the registry and QCDRs is that the QCDRs will also have a QCDR
Sub-tasks tab or option, and that QCDRs may use to submit their own measures for CMS consideration.
Please note that all measures, whether they are new or previously approved measures, should
be submitted as sub-tasks.
And as just previously mentioned, we are providing a QCDR measure submission template that you
can use as an alterative to creating sub-tasks.
Also, a Resources tab will be added to the form when you go to self-nomination, and the
Resources tab will contain links to the 2018 self-nomination user guide, fact sheets, and
a QCDR measure submission template.
The QCDR measure template, again, is an alternative to creating some tasks and can be used to
submit all of your measures for CMS review.
The 2018 self-nomination user guide, fact sheets, and QCDR measure submission template
are anticipated to be posted by September 1st.
An e-mail will also be sent to those participants registered for today's demonstration, and
that e-mail will include a link to the resources that I just mentioned.
So, in terms of the QCDR self-nomination form, all fields marked with a plus sign contain
information that will be included in the qualified posting, and the fields noted with an asterisk
denote information that's required.
So, I'll go through one quickly with you on the phone.
Make sure that you have your organization name.
If the QCDR name is different than the organization name, please note that on the form.
If not, you may enter "n/a."
You may enter your street address, suite number, city, and state.
And again, this information will be used to generate your qualified posting for your organization.
Website, your telephone number.
This is new, as well, for this year.
We're asking for the telephone number.
Sometimes we find that it may be easier just to pick up the phone and speak with someone
directly instead of going back and forth through e-mail or through the JIRA comments function.
So, this year, again, we've added the telephone number field to try to expedite that process.
You enter your application name.
Please indicate how you would like your self-nomination form to be saved -- for example, "ABCDQCDR."
We also ask that you include your vendor organization staff -- so, other folks that you would like
to be included in any communication that's done through JIRA.
They must also have a JIRA account to be able to either access the system or receive those
notifications.
And we're also asking if you're a new or existing QCDR under MIPS, what years you participated
under MIPS or PQRS, if you have an alias and if you have any previous aliases for your
entity either under MIPS or PQRS, a description of your QCDR, whether you plan to risk-adjust,
and if you will do your own public reporting or whether you'll be reporting through the
Physician Compare site.
We also ask for cost.
In terms of cost, we also ask to please clarify if the cost is monthly, annually, per submission,
per provider.
That was one of the fields last year where we needed to go back to a number of vendors
for clarification.
So, the more information you provide on the self-nomination form, the easier it'll be
for us to review in the staff so that we can get through the self-nomination form review
for your organization.
Services included with the cost, the data submission mechanism.
If you select Other, we also ask that you please specify here in that field what that
other mechanism will be.
Also, if you're reporting for Improvement Activities, Advancing Care Information, or
if you're only reporting for Quality.
If you're reporting Quality and any of the other two, such as Improvement Activities
or Advancing Care, please select those, but if you're only reporting for Quality, please
select the last box.
And also reporting options supported -- whether it's individual MIPS-eligible clinicians,
groups, or virtual groups.
And as mentioned earlier in the presentation, the reporting options supported may change.
Please review the calendar year 2018 Quality Payment Program final rule for that information.
We also ask for three organization contacts, and we encourage that you list three different
individuals as organization contacts.
This will ensure that your entity does not miss important correspondence due to staff
changes, staff limited access to e-mail -- if staff is out on vacation or out of the office.
This will ensure JIRA notices are received, so please have these contacts add ONC JIRA
to their safe or approved senders list.
For the next half, for the individual measures...
Sorry about that.
I'm just filling it in so I can show you how to submit a sub-task at the end.
In terms of individual measures, again, you can select here which Quality Payment Program
and quality measures you will be supporting for 2018.
And again, as a reminder, that might change based on the 2018 Quality Payment Program
final rule.
So, if you're going to be supporting all of them, you can select all or you can select
individual measures from the drop-down here.
The same applies in terms of the QPP eCQMs, whether you plan on supporting any of those
measures.
In terms of the data validation plan, as mentioned earlier, you can upload that on the Uploads
tab and enter See Attachment if you like, if you have a plan already.
Please note that if you previously participated in PQRS that you should update your data validation
plan to reflect the MIPS Quality Payment Program in your data validation plan.
If you plan to benchmark, how will your organization verify?
In this field, we ask that you describe how your organization will verify the eligibility
of eligible clinicians or groups -- so, whether you would use a Medicare provider and bill
Medicare Part B services.
We also ask how your organization will verify that accuracy of TINs and NPIs.
We also provide further guidance here.
The method that your organization will use to verify the accuracy, such as the national
provider identifiers -- So, if you're going use NPPES, CMS claims or tax documentation
to do so, we ask that you specify that here in your data validation plan.
What method your organization will use to calculate the reporting and performance rates,
and how will your organization verify the 2018 QPP and QCDR measures.
And again, we'll ask how you will complete the randomized audit, as well as the detailed
audit, and these two should not be the same.
We've also included some minimum requirements.
So, for a randomized audit, the minimum must meet the following sampling to meet participation
requirements -- so, sample three percent of the 10 NPIs submitted to CMS by the QCDR,
with a minimum of 10 TIN/NPIs or a maximum sample of 50 TIN/NPIs, at least 25 percent
of the TIN/NPIs patients, with a minimum sample of five patients or a maximum of 50 patients
should be reviewed.
You can also find this information in the 2018 or 2017 Quality Payment Program rules.
And again, if you would like to submit or upload your data validation plan, your benchmarking
capabilities, any supplemental QCDR measure documentation, you can do so on this tab here
under Uploads.
So, once you've done that, you can select Create.
And it'll create the ticket for you.
And note if you're a QCDR and you would like to submit the sub-task on JIRA you may do
so by coming to the More field and selecting Create Sub-task.
Now, if some of you are on the phone and you're currently participating in the program, you'll
notice that this Sub-task area has changed.
We've added more fields to this part of the form to try to reduce the number of times
that we have to reach out to the vendors to get information.
So, we're trying to collect a lot more of that information up front to try to make the
process, again, more efficient for this go-around.
So, we ask if it's a new proposed measure, and then we ask what measure type it is for
a QCDR.
So, is it a new measure?
Is it an existing measure with no changes?
Or is it an existing approved measure with changes?
Does this measure, again, belong to another QCDR, and, if so, which one?
This again will help in terms of harmonization or letting
us know that you're submitting a measure that's owned by another entity.
And we also ask that you check one whether you have been granted permission to use this
measure or if it's not applicable because this is your measure.
Again, if you do use another QCDR's measure, we do ask that you receive written permission
when you self-nominate and that you include that with your self-nomination.
If you're an existing approved QCDR, we ask for your CMS-assigned measure I.D. number
that was provided to you as part of the measure specifications.
And if it's a brand-new measure, you can select N/A for this field.
The application type for the field, the description of the measure, and here you'll start seeing
other or new fields that we've added for this year to reduce the number of communications
that are sent out.
So, is it a high-priority or an outcome measure?
If it is a high priority, we ask you to specify which one it is, which domain it falls under.
We also ask for the NQS domain and for you to provide rationale for selecting that NQS
domain.
We ask you for the measure specifications, which is similar to last year.
The biggest change is that we separated out the exclusions and the exceptions.
And we've also included a Numerator Exclusions field this year for you to be able to provide
that information.
Another new field that we've added is if the measure is an inverse measure.
The measure type you can select from the top down.
How the measure is scored -- if it's a proportion or a continuous variable and if it's a ratio
measure or not.
And we also ask for the range of those scores if it's a continuous variable or ratio measure
if that's chosen.
Also, we ask if the measure is risk-adjusted.
And if the measure is risk-adjusted, we ask how it's going to be scored.
We also ask that you submit your risk-adjustment methodology, as well, with your self-nomination
for 2018.
The NQS I.D. number for that measure -- if one does not apply, you can enter zeroes in
this field.
And the source used for the measure.
Is it claimed?
Is it the EHR facility discharge, things like that?
The number of performance rates to be submitted in the XML.
You can enter the number or N/A. If only one is calculated, just indicate that by the number
one.
We also ask that you provide the name for each performance rate if there are multiple
performance rates for that measure.
So, if it's a multi-strata rate or multi-performance-rate measure, we ask that you specify that in this
field.
And we also ask that you indicate an overall performance rate if more than one performance
rate is submitted.
We also ask that provide a concise summary of evidence of a performance cap in addition
to any study citations.
The citations are great, but if you could provide a one-paragraph or two-paragraph summary
of the citation or citations or the study there submitted, that would also help us during
the measure review part of the process if we need additional information or, again,
just to help us with the review process.
And then we have some fields here at the bottom in terms of indicating which specialty or
specialties this measure applies to, if there's any variance in the measure rate.
If there is, we ask that you indicate the variances within your registry or another
source.
If it's another source, please cite the source.
We ask that you please provide any test data or reliability validity data, and also what
is the measure funding source.
And once you're done, again, you can hit Create, and it'll create that as a sub-task to your
self-nomination form.
Once you finish the process, if you do the self-nomination registry form, once you hit
Create, it is automatically sent to CMS.
But for the QCDR, since you do have the option of adding QCDR sub-tasks, you do need to click
here to submit to CMS for review.
Again, if you submitted your 2018 self-nomination form to CMS prior to the close of the self-nomination
period and your application is ready for review, we ask that you notify the PIMMS/MIPS team
by e-mailing us either at the qcdrvendorsupport@gdit.com or registryvendorsupport@gdit.com
so that we can begin with the self-nomination review process and can start processing your
application as soon as possible.
And you'll see those sub-tasks listed here for your organization.
We can go to the Q&A session now.
Okay, great.
Thank you, Hector.
And just as a reminder to all the attendees, only questions pertaining to QCDRs, registries,
and the self-nomination process will be answered during this Q&A session.
Okay, so, the first question we have is, "On slide six, it says you must provide a statement
during the data submission period verifying that all the data is accurate.
If participants are uploading the data to our registry QCDR, is the participant also
agreeing to this attestation statement?"
So, I assume we're talking about the attestation statement that the data is true and accurate
and complete to the best of the entity's knowledge.
So, different registries and QCDRs are going to have different agreements with their eligible
clinicians.
Some as a requirement for participation -- I think it's STS perhaps, Society of Thoracic
Surgeons -- I believe their doctors are obligated as part of their condition of participation
with the registry/QCDR, to submit all of their cardiac surgeries that are applicable.
So, again, it really depends on the agreement the entity has with their clinician.
Great.
Next question -- "If you are a new QCDR, do you still need 25 participants?"
Yes.
You don't have to report on all 25 people to us, but you do need to have 25 people that
are submitting data to you.
Great.
Next question -- "Where can the application for self-nomination to become a qualified
registry be found?"
So, the self-nomination application is available through the ONC JIRA system, and we will be
providing additional resources within the next day or two, a self-nomination user guide,
and some fact sheets that will assist you with logging in to the website and creating
the account and starting your application.
Next question -- "Is there a more summarized, concise source for the 2018 QCDR requirements
other than the proposed rule?"
Yes, we actually have a 2018 QCDR fact sheet that will be available within the next day
or two.
We will distribute that through list messaging, and they will be posted on the CMS website,
so please stay tuned for that.
Next question -- "Does 25 participants mean 25 TINs or 25 clinicians?
Clinicians.
Okay.
Next question -- "If we want to change the name of our QCDR, do we do so on the self-nomination
form, or is there another way we need to do that?"
If you're an existing QCDR and you would like to change your name for the 2018 performance
period, you can do that in your self-nomination application.
Just list your new name in the title of application, but then in the previous alias, if you can
list your 2017 name for our reference.
Okay.
Next question -- "If you a new QCDR and are unable to sign a contract with 25 participants
by January 1, 2018, are you ineligible for 2018?"
We're really looking for people to have 25 participants on board at the time of self-nomination.
Again, you don't have to report on 25 clinicians.
Maybe only five of them will ask you to report for them.
But what we're looking for is we want entities with proven track records that have been collecting
and analyzing and providing feedback reports to eligible clinicians so that when your clients
are playing for all the marbles, so to speak, it's not a learning process for you guys with
high risk of not being successful.
So, that's part of the reason of the requirement for 25 people before you self-nominate.
Next question -- "Will CMS publish a template or guidelines for the 2018 data validation
plan?"
So, in the 2018 QCDR/registry fact sheets that are coming out, we do go into more detail
in terms of what we're looking for, for the data validation plan, and we pull these requirements
directly from the rule.
So stay tuned for that, as well.
Next question -- "Can QCDR submit specialty measure sets?"
Specialty measure sets that have been identified in MIPS?
If the question is that, yes, but we do ask that QCDRs -- and feel free to correct me
if I misspeak, Sophia -- we do ask them to report on six measures.
I mean, everybody has to report on six measures in theory, but some of the specialty sets
have fewer than six measures -- again, not a lot, but a few.
So, that's the one caveat.
Sophia, if you want to elaborate.
No, that's accurate, Dan.
I think you covered it well.
Great.
Next question -- "Can a qualified registry support measures that were not listed at the
time of self-nomination for a given program year?
And is this true for 2017, as well?"
Sophia, you want to take that?
Yeah, sure.
So, we encourage our vendors, our approved vendors, to, when they self-nominate, include
all the measures as much to their ability in their self-nomination application.
We have allowed vendors to add additional measures up until a certain point.
But that wouldn't be throughout the performance period.
It's for perhaps a few weeks to a month that we will let them add that information.
And we have an internal process that our existing vendors are aware of, of how they can add
existing quality measures to their self-nomination if they choose to do so.
Okay.
Next question -- "Are the lists of 2018 QPP measures released?
And do we need them for self-nomination?
So, currently the list of 2018 quality measures is available through the proposed rule and,
once finalized, will be in the final rule.
We are working to get those posted I believe -- Dan, correct me if I'm wrong -- by the
final rule on the QPP website.
And so intermittently, we do have the measure numbers included in the self-nomination form.
So, as you scroll through, you can kind of do a comparison to the number that's there
versus what's in the rule, and the rule will give you the exact
measure specification that's available.
Okay.
Next question -- "What is the non-technical criteria used to determine if an organization
is approved as a QCDR?"
So, our largest aspect is looking to see that they have completed the data validation plan
to meet the requirements of the program, their ability to audit, their ability to verify
TIN and NPI combinations.
So, we're really looking to see that they can do that.
Other than that, if you're a QCDR and you're trying to self-nominate -- non-MIPS or QCDR
measures we're referring to -- we look to see that the organization is either a medical
society or a specialty society or perhaps the I.T. vendor that's collaborating with
the specialty society that has the clinical background to support the measures in which
they are choosing to self-nominate.
So, the requirements are largely around those areas that we look to see, but, as Dr. Green
had mentioned before, the 25 participant requirement is one thing we also really do look at, so
please stay tuned for additional information on that with regards to the fact sheet.
That will be available soon.
Thanks.
Next question -- "Can you please clarify the difference between a randomized audit and
a detailed audit?"
I'm not 100 percent sure I understand the question.
If you're talking about a randomized audit that we may randomly select, QCDRs are eligible
clinicians to audit.
That would just be kind of a luck of the draw for the clinician or QCDR.
If we're talking about audits that the QCDR or registry should do for their eligible clinicians,
we do expect that there will be some sort of data validation that is done to ensure
for a small percentage of the clinicians for whom the registry or QCDR submits.
We would expect that they would go back and look, again, for some small percentage of
their clients to make sure that the information was, in fact, correct.
So, it's a random kind of luck of the draw of their clinicians or if there's a clinician
that they have particular concerns about because of some data peculiarity in the information
that was provided to the registry.
Okay.
Next question -- "Can we add additional non-MIPS measures to our QCDR after the close of the
self-nomination deadline?"
So, we do not accept additional non-MIPS measures after the deadline.
We ask that you submit those by November 1st for our review.
We will, on a case-by-case basis, allow you to add quality measures that are in the program,
MIPS quality measures.
But we do not accept non-MIPS measures after the deadline.
Next question -- "What happens if all of our 25 participants back out and we are unable
to submit data at the end of the year?"
I'm sorry.
Can you repeat that last question?
Yes -- "What happens if all of our 25 participants back out and we are unable to submit any data
at the end of the year?"
I believe -- The clinicians are not obligated to report.
Nor are the QCDRs.
They just have to have 25 to start.
Okay.
"As an integrated health system, are we eligible to self-nominate and become a QCDR?"
I guess that would depend on if they could meet the technical requirements and the clinician
requirements of becoming a QCDR.
So, if you can meet the definition, then you can apply to be considered as a QCDR for 2018.
Okay.
Next question -- "Does data have to be collected directly from clinicians, or can a third party
be used?"
I'm assuming that's asking if data has to be submitted from the clinician directly to
CMS, but, no, you can use the third-party intermediary to submit data on behalf of clinicians
to CMS.
Okay.
Next question -- "Do approved and existing QCDR measures mean it was approved for use
in 2017?
Is the sub-task where we would put our non-MIPS measures?"
So, I guess that was a compound question.
Sure.
But let me know if you need me to repeat it.
No, I think I got it.
So, the sub-task is one of the places where you can add your -- if you're an existing
QCDR and you have an approved 2017 non-MIPS -- or we are referring to it now as a QCDR
measure -- in the program and you would like to re-self-nominate that for 2018, you could
either fill out the sub-task -- and you can identify that it is an approved measure and
whether that be with changes or still the same from last year -- or you can -- and we
didn't have a chance to show you this, but we will distribute it with the other 2018
resources.
There is a QCDR measure template, and it's in the format of an Excel spreadsheet.
And you can also include the information in that spreadsheet in lieu of a sub-task that
we will review as a part of QCDR self-nomination review application process.
I'm sorry.
Did I answer the second part of the question?
I believe so, the sub-task part, yes.
Okay, great.
Okay.
"Do clients of the QCDR and certified registries have the ability to evaluate companies they
have worked with?
If so, is this information available to the public?"
I guess like a review?
I'm not aware that they're able to review -- Well, CMS doesn't post anything in terms
of client reviews of vendors, but we do post on a yearly basis the qualified posting, which
lists all of our approved vendors and the services they offer with the costs they offer
and performance categories and measures.
So, that is available for the public.
The next question is, "What are the requirements for public reporting if we elect not to use
Physician Compare?"
We would expect you to post all the results for the people and the information that was
provided to you.
Great.
Next question -- "In addition to several MIPS quality measures, would proposing several
more new QCDR measures as part of our self-nomination hinder our prospects at successfully achieving
approval as a QCDR?"
Sorry -- what part of that was the question?
They were asking if proposing several more new QCDR measures as part of their self-nomination
would hinder their ability to successfully be approved as a QCDR.
No, that would not.
It's an option.
QCDRs have the option to submit for consideration QCDR measures.
And they are not required to do so.
You can also support just quality measures.
But that would not hinder their application or their review.
Next question -- "If participating in prior years as a registry, can we change to a QCDR
and meet the criteria of the previous year's participation?"
Not necessarily.
So, we're looking for QCDRs to be affiliated with regional health collaboratives of specialty
societies or at least be large-scale institutions like a Cleveland Clinic, Johns Hopkins, health
plan -- so, you're talking about large, multi-specialty organizations.
We're not looking for ABC EHR suddenly converting from a registry to a QCDR.
Okay.
Next question -- "As a first-time applicant, I'm wondering what the definition of a QCDR
measure is.
Are those measures different from the measures already finalized in MIPS?"
Yep, a QCDR measure is different from those that are finalized in the program.
We do define that more clearly in the fact sheet, but it is a measure that addresses
performance gap.
It is not a standard-of-care-related measure.
It's something that performs a quality action.
We have a checklist of criteria that we do use, and I believe we did include that in
the QCDR fact sheet that will be coming out in
the next two days.
Next question -- "Do 25 participants mean 25 groups or 25 physicians irrespective of
how many groups they belong to?"
The latter.
Okay.
Next question -- "Can a qualified registry also be a Certified Electronic Health Record?"
Not a qualified clinical registry unless they are functioning in conjunction with, again,
a specialty society or a regional health collaborative or something more than just the fact that
they're an EHR.
Okay.
Next question -- "You stated that all 25 participants' data needs to be submitted to CMS, just to
the registry.
Is there a minimum amount of data that does need to be submitted to CMS?"
So, when you sign up, you have to basically represent that you have 25 people participating
with your entity.
In the end, these folks, all 25 -- or you may get more people on board during the year
that want you to submit to CMS, or none of them may want to participate in the program.
So, we don't require that you submit that data.
However, if we were to look into your self-nomination and/or audit you in that respect, we would
expect that we would find there are 25 clinicians that you're providing feedback to and collecting
information at the time of your self-nomination.
So, again, in the end, they may not decide to participate this year, and that's fine,
but you have to have the experience of collecting
information from at least 25 clinicians, giving them feedback -- so, processing the measures,
calculating the results, and giving them feedback before you can self-nominate to our program.
You can imagine -- and even with this requirement, we've had folks -- registries and QCDRs -- that
have not been successful at getting data in on behalf of some of their clinicians, which
puts us in a tough bind because there are penalties.
At least, there were with PQRS.
So, if there's no data submitted, that particular clinician is automatically going to get a
four percent payment adjustment, again, under PQRS.
And we don't want to penalize people for something beyond their control, so we have to have as
best an assurance as we can to make sure that you all are able to submit the data properly.
Next question -- "Can you begin the application process, save it, and then add to it over
the course of the self-nomination period?"
So, when you create your self-nomination form, you can actually -- between September 1st
and November 1st, you can create it and click "submit to CMS," and though it will be routed
to us, you have the ability to go back and edit your application.
So, if you decide between now and then you wanted to add a few more measures and it's
still within the time frame of self-nomination before November 1st, 5:00 p.m., you can hit
the edit button.
And you have the edit function now.
You could go in and make some additions or removals as you see fit.
Next question -- "How are the data inaccuracies calculated?"
So, the data inaccuracies would be calculated by looking at various pieces of information
that we receive, both from the QCDR or registry, as well as what we're able to collect from
claims.
There also would be information that we receive from the registry or QCDR itself during their
data validation process or through their data validation execution report.
Examples of things that we look for are incorrectly calculated measures, incorrect TINs or NPIs,
just to name a few.
Next question -- "For issues and comments that come up regarding requests for harmonization,
how do you want us to communicate with CMS?"
So, for those kind of issues, with harmonization, if you're an existing QCDR or you're planning
to be one for 2018, please contact the PIMMS team at qcdrvendorsupport@gdit.com.
Okay.
Next question -- "If you have a QCDR with 10 LLCs and there are 10 clinicians under
each LLC, does that meet the 25-participant requirement?"
I believe so, but, Dan, can you verify?
Can you repeat the question, please?
Yes -- "If you have a QCDR with 10 LLCs and there are 10 clinicians under each LLC, does
that meet the 25-participant requirement?"
It would.
That would be 100 clinicians.
Okay.
Next question -- "Can the measure information page data be submitted as a Word document
and uploaded, or do all the fields have to be filled out?
Is there a specific format for submitted results of the data audit plan?"
So, this is a two-part question, as well.
So, the first part of the question was with regards to the QCDR measures?
Yes.
Okay.
Yes.
So, the QCDR measure -- if you choose not to fill out the sub-tasks, you would have
to put in "Please see attached" or something of that nature in the field because it wouldn't
let you submit otherwise.
And you can attach your document.
We prefer that you use the QCDR measure template, which is in Excel format.
It just ensures that you capture all the information that we need for our review and minimalizes
the number of times we have to request information from our vendors.
So, if you could please use that, we'd prefer it.
The second part of the question -- can you repeat that?
Yes -- "Is there a specific format for submitted results of the data audit plan?"
I don't believe so.
Dan, is there one that you're aware of?
What about the data validation plan?
I'm sorry.
I missed it.
Is there a specific format in which it should be submitted?
Well, I think we do -- and I don't know if Anastasia's on the call, but I do believe
we provide -- I don't know if it's a template, exactly, or an example.
This is Anastasia.
So, we don't provide an example, per se, but within the JIRA form, there are different
fields that we request specific answers to.
And then of course the self-nomination fact sheet just contains some information regarding
the requirements of kind of what we're looking for in those validation plans.
And then of course if you do have specific questions about any of those components, you're
more than welcome to submit an incident through your QPP Service Center, and we can certainly
walk you through that and provide more information.
Okay.
Next question -- "Why is there a max of 30 QCDR measures?
And will this change?"
We don't have any imminent plans to change the number.
The 30 is partly due to resources to be able to review them, but at the same time, since
clinicians only have to report on six measures, that's quite a few measures that they can
choose from.
We don't say, for example, that ABC vendor, in collaboration with the dermatology -- I'm
making this up, of course -- the Dermatology Society of America could be one QCDR.
ABC vendor in conjunction with the Orthopedic Associates of America could be another QCDR.
So, you can have multiple QCDRs, as long as each one meets the requirements.
And each one, in theory, could have 30 QCDR measures.
But that's kind of the rationale behind it.
Again, you should know that we do go through these measures and we do try to hold them
to a very similar standard to measures that we place on our Measures Under Consideration
list, which would be measures that we would potentially evaluate
for inclusion in the program as a whole.
Okay.
Next question -- "Can a given QCDR address the MIPS needs of multiple specialties?"
"Can a MIPS QCDR --" Can you repeat it again?
Yes -- "Can a given QCDR address the MIPS needs of multiple specialties?"
They're not precluded from doing that.
You might have a QCDR that is using all primary-care type measures.
And you may have a gastroenterologist that feels that those measures represent his or
her practice well and decide that they want to participate.
Unless there's a rule against participation in the QCDR by the QCDR -- in other words,
if they limit it to certain types of specialties -- that would be on them.
But we don't say that a G.I. doctor couldn't report on an orthopedic QCDR.
I can't imagine that they'd want to, but there's no prohibition against it from CMS.
Okay.
"If we did not mention about ACI and IA reporting at the time of registration, can we still
support it later in the program year?"
I don't believe so.
Sophia, can you confirm that, please?
Yeah, you're correct, Dan.
We do ask for that information at the time of self-nomination, and if you, in between
our review, decide to add that, we do take it into consideration.
But once the services and the QCDRs and registries have been approved and finalized, we post
your services and your performance categories on our website, so we do ask that you make
those considerations when you make your decisions about what you plan to offer as services.
On top of it, I think that the production team also may code the system to look for
certain types of information.
I'm not 100 percent on that, but that does ring a bell.
Okay.
Next question -- "Is there a minimum number of MIPS-approved measures that a QCDR must
support for 2018?
Can a QCDR support only non-MIPS measures and still be approved?
Yes.
Go ahead.
Sorry.
Go ahead, Sophia.
So, I was gonna say, a QCDR can support both, obviously, but if they choose to only support
non-MIPS measures, they have to make sure that they have at least six and one of them
is at least a high-priority or an outcome measure.
And so what we do in our review -- if a QCDR only submits six non-MIPS measures and they
don't submit any quality measures and for some reason that one measure is rejected,
leaving them with only five approved measures, we do go back to the QCDR and we do ask them
to add a quality measure to get them up to that six because six measures is the minimum.
Whether it be a QCDR measure or a quality measure or a mix of both, we ask that you
support six in order to participate in the program.
Okay.
Next question -- "If you select all QPP measures for the QPP measure selection, is that for
registry claims measures only, or would that include all QPP eCQMs, as well?
So, since there is a different tab that distinguishes eCQMs from the QPP measures, we would take
the all-QPP measures to represent those that are for registry or the claims-based measures.
So, if you want to do the eCQMs, you would have to fill out the eCQM tab, as well.
Next question -- "Does CMS validate data at the time of self-nomination, or is it only
after the completion of the performance year?"
So, we validate the data that's submitted during the performance period after the submission
period is closed.
Okay.
Next question -- "If we submit an application to be a QCDR, we enter the measures that we
intend to support after the specifications are released and we find there is a measure
or measures we cannot report due to limitations in our workflow, can we withdraw those measures?"
So, if we're speaking about the MIPS quality measures that are in the program and you see
that, between your approval and the time -- there is a time in between where we have our approved
vendors review their qualified posting before it's posted.
So, if in that instance you see that there's a measure you can no longer support, that
is your last opportunity to let us know that you cannot support that measure, and we will
remove it from your posting and make note of it in your application just for our reference,
but that's the last time we can actually remove a quality measure from your posting.
Okay.
Next question -- "Do QCDRs have to submit the QRDA style provided by clinicians?"
So, they don't have to.
If a clinician is reporting an eCQM in QRDA III, they stand to get an extra bonus point
for electronic submission.
So, your clinician is going to be very unhappy with you if you can't support that and that's
how they want to report, especially if you advertise as being able to accept electronic
measures.
So, that's kind of the caveat there, if you will.
There's no requirement from us exactly, but you would be cheating your clinician out of
a bonus point.
Okay.
Next question -- "How is the audit different from the data validation?
What's the difference between the processes?"
So, if we audit you guys or your clinician, we're going to request records and charts
and whatever.
If you do a data validation of your clinician, you may request the same things, but it would
be you doing it versus us doing it.
Okay.
Next question -- "For non-QPP QCDR measures, is there any issue if no physicians end up
selecting them for reporting to CMS?"
Are there any issues if people don't want to report the QCDR measures?
Yes, I believe that's what the question is asking.
No.
Okay.
Next question -- "How does the sampling methodology work?"
Sampling methodology.
Anybody else understanding the question?
Dan, I think they're referring to the sampling methodology.
We asked them for the randomized audit.
I believe it was at three percent.
That's up to them then.
I think they're asking what our requirement is.
Hector?
Do you or Anastasia want to take that?
Yeah.
This is Anastasia.
I can definitely tackle that.
So, as suggested in the self-nomination fact sheet for all of the eligible clinicians,
as well as the various measures and instances that you report on behalf of, we encourage
each vendor to audit a certain sample of that data you're submitting to ensure that the
data you're submitting is accurate, complete.
It does of course apply to what's written in the measure specification and it's been
calculated correctly and whatnot.
So, this is just asking you to take a certain percentage or a portion of your data to just
verify that everything is, in fact, correct.
And then I believe part of that is also to submit after, of course, you collect this
data and submit it to CMS for the data validation execution report.
CMS would like to see the results of that sampling methodology to see what you found
in your results.
You know, was there inaccurate data?
Did you find that perhaps something wasn't coded correctly in your system?
Or perhaps a measure wasn't calculated correctly.
Or maybe everything was perfect and you guys were rock stars.
Whatever you guys happen to see when auditing that data is kind of what we'd like to see
in the execution report.
And of course that wouldn't be due until after the submission, so it would be well into 2019.
Okay.
Next question -- "Can the qualified registry get clinical data from the practice's claims
data or from their payers?"
Can you say that again?
"Can the qualified registry get clinical data from a practice's claims data or from their
payers?"
They can get the data from -- I'm not understanding.
Sophia, are you understanding the question?
Not really.
I think we need some clarification from the questioner.
Okay.
This is Anastasia.
I might be able to tackle this one.
In reading the specific question in the box, it sounds as if they're just wondering if
they can actually use claims-based method for their data-collection method or collect
that data and then calculate accordingly from claims.
Yeah, I mean, they can get a copy of claims if they want as their data source if the clinician
is, in fact, listing -- I'm sorry -- if the clinician is appending quality data codes.
Okay.
Next question -- "The result of the executed data validation plan must be provided by May
31 of the year following the performance period, but in what form and manner?"
So, basically we're asking that you go out and you -- if it's a certain percentage of
clinicians that you're going audit or whatever, that you are going go out and perform that
audit and write up, you know, "We audited X number of clinicians and we looked at Y
number of charts and this is what we found.
The data was accurate.
Two percent of clinicians had inaccurate information."
Whatever it was.
I don't know what else to say about that.
Anastasia or Sophia, do you have anything else to add?
Anastasia, is there anything with the format?
I know we discussed -- I guess what Anastasia had mentioned earlier with the data validation
plan -- those specific questions we ask in the self-nomination form and basically your
responses to that and how you executed each aspect of that data validation form would
probably be like, I'm assuming, in a Word document or something like that, as in a report
for us to review.
But that's all I have to add.
Yeah, Sophia, that's absolutely correct.
Sometimes we will get it in a Word format.
Sometimes we do get it in Excel.
The one thing I will say is, just because different vendors develop their own validation
plans and then execute them in a wide variety of different methods and whatnot, it's hard
for us to develop one sort of template that will apply to all vendors because each of
you may be doing your validation in different mechanisms.
Maybe some of it's being exported from a system.
Other folks may be generating it manually.
In addition, the various ways folks collect data, whether it be claims, Web-based tool,
practice management system, EHR, there may be different ways to validate that data in
that mechanism, as well.
So, we've found that just letting the vendors identify the best mechanism to send in these
reports has been the most ideal just because there is such a wide variety of different
ways to validate the data that folks are sending in
and collecting.
Okay.
Next question -- "Irrespective of if a practice participates in MIPS via our qualified registry
or a QCDR, are they still able to pick your pace, do the test submission in one chart
for 2018?"
Sophia, I'm gonna pass that one to you.
I think we need to take this question back to the team.
I'm not sure because this is asking of the 2018 performance period, and since the rule
hasn't been finalized -- Good call.
Yes, that's true.
We can't answer that question in this period.
Yeah.
Okay.
Great.
Thank you all.
I did want to note that it is 2:29 right now, so I'll leave it up to the presenters if we
would like to take one more question or close out the call for this afternoon.
I just wanted to clarify one question that I see in the Q&A box because it was related
to an answer that I provided earlier with regards to whether the QCDR could support
only QPP measures or not.
QCDRs can support QPP measures that are MIPS quality measures that are already in the program
as established by the rule, or they can submit QCDR measures that are owned and developed
by the QCDR.
Or they can do a mix of both, but they're not required to do one or the other.
It's up to the QCDR and their capabilities.
That's the only clarification that I wanted to make.
So, I think if we're done, I just want to thank everybody for your interest in the program
and your potential interest in participating.
We hope this call was helpful.
There will be additional information that's posted on the cms.gov website in the next
day or so.
We would ask you to look out for it, and we will provide links once we have them available.
Thank you, and any additional questions that were not answered today, feel free to submit
them to the QPP portal -- and Sophia can run through that address real quick before we
hang up -- and we will route them to the appropriate subject-matter expert.
Thanks again for dialing in.
Sophia, do you want want to give that address real quick?
Sure.
So, it's the Quality Payment Program Service Center, and the e-mail address is qpp@cms.hhs.gov.
And your question, whether it be related to quality, ACI or IA or scoring or any of the
other policy related areas, will be directed to the appropriate subject-matter expert for
an answer.
Thank you all.
Have a good day.
Bye.
Thank you.
This concludes today's conference.
You may now disconnect.
Speakers, please hold the line.
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