Tuesday, 13 December 2016 19:53

A Retrospective Review of Quality Reporting

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Like tax folks in early April, we healthcare value improvement people, are entering the beginning of our busy season. We survived the first round of the eligible professionals’ appeals to the Centers for Medicare & Medicaid Services (CMS) regarding their 2017 penalty designations. These “informal reviews” aren’t up for second opinions, but through networking with CMS officials, we recognized that there were a number of glitches with the processing of the 2015 data – which greatly influences how we are advising clients for the 2016 data submission cycle. 

Is it too Late to Get Started?

This time of year, we get a ton of calls from frantic business managers in outpatient settings on whether or not they should just throw in the towel when it comes to quality reporting for 2016. It isn’t too late! 

While some quality data vendors may have closed their enrollment for 2016 submissions, that date is unique to each vendor. Vendors have until March 31, 2017 to get data to CMS. So you won’t have until March 31 to enroll, because it takes time to validate each provider and then upload data to CMS; some vendors will be accepting enrollment until early spring 2017. Why not get started now, and find your vendor partner!

Likewise, if you are reporting individually and worry that you don’t have enough data yet, the guidance from CMS is that you must address the quality metrics during the reporting year, which ends Dec. 31. It’s a great time to get your documentation completed and run audits while you may have fewer patients. And remember, double-check if one of the 25 measure groups makes sense for you (20 patients, and 11 or more must be traditional Medicare patients, with reporting done on a defined set of measures based upon the services you provide). Measure groups go away in 2017, so take advantage of them now. 

Stay the Course

For the sake of everyone’s sanity, let’s forget about the recent election and the new president and Congress convening in January. Instead, let’s focus on the fact that the quality reporting programs, electronic medical record mandate, and electronic prescribing requirement have been around for over a decade as either an incentive or penalty for eligible professionals billing Medicare.

And while the Merit-Based Incentive Payment System (MIPS) tweaks and streamlines the existing programs, the fundamental apparatus is still there. Even for those who are betting on Congress dismantling Medicare as we know it and implementing Medicare Advantage for all Americans by Feb. 1, I say if it ain’t broke, don’t change it. I counsel my friends, colleagues, and clients to keep doing what you are doing with quality reporting, electronic prescribing, and electronic medical record use. Let’s go for the gold and not rip up the railroad tracks of workflow that have already been laid, confusing medical assistants and support clinical staff on their roles and job expectations. And honestly, what’s the harm if I am wrong? 

Outsourcing Quality

The most important thing that we in our provider community needed to appreciate this year is that CMS has outsourced its quality evaluation to several contractors. That means we have run into numerous hurdles getting questions answered or problems fixed, because the government agency and contractors weren’t aware of some of the same information or able to access the same data. 

  • QualityNet (Ventech Solutions, Inc.) – This is the helpdesk for the majority of the congressionally mandated “value-based purchasing” quality programs, including the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM). However, they don’t process the data; they just host the helpdesk, also known as the Health Care Quality Information Systems (HCQIS) Infrastructure and Data Center Support (HIDS).

    We have found it best to submit emails (to This email address is being protected from spambots. You need JavaScript enabled to view it.) rather than spending hours waiting for your call to get non-answered. The email process auto-generates a processing number, which is crucial. It also allows for faster transfer of questions to the appropriate subject matter expert. Plus, you get wrong answers from the helpdesk in writing. Be sure to keep copies of these responses, because you may need them in the future. And currently allow a week (seven business days) for processing.

    We are aware of accuracy issues wherein QualityNet isn’t aware of announcements made by other parts of CMS or related subcontractors. For example, QualityNet wasn’t processing requests from organizations to change their Group Practice Reporting Option (GPRO) designation or reporting modalities that were due by Nov. 25, 2016 (there was no formal announcement made other than one directed toward data submission organizations). Likewise, QualityNet can’t answer questions about the 2017 program yet – those are transferred back to CMS for response.
  • PQMM (Signature Consulting Group) – This is the management arm staffed by Signature Consulting Group that oversees and maintains the PQRS measures (soon-to-be-called MIPS measures) through its Physician Quality Measure Management (PQMM). This is the correct group, other than the measure author, to contact for questions about measure specifications. They can be contacted through the QualityNet Help Desk – so be sure to note in your email that your question is a measure specification question and should be routed to PQMM.

    The number of 2016 measure specifications not easily understood by our clients is growing. And several of the measures proposed in 2017 do not reflect MIPS program changes. The 2017 measure specifications are available online at https://qpp.cms.gov/education (scroll down halfway to “Learn More About the Merit-Based Incentive Program,” and the measures are under “Measure Specifications Download”) on “preview” with “final measure specifications will be posted by Dec. 31, 2016.” Although a bit late, comments may be directed to this organization for requested changes to troubling and confusing specifications (along with the measure author).
  • PQPMI (Newwave Telecom and Technologies, Inc.) – This is the group processing the PQRS data (with a 2-percent penalty for failure to submit data on Medicare receipts two years after the reporting cycle; 2016 data affects 2018 payment). They process the quality data coming in from Medicare claims, registries, electronic medical record (EMR) vendors, QCDRs, and the CMS Web portal, then create the PQRS feedback reports, publishing them on portal.cms.gov. This contract is called the Physician Quality Programs Management and Implementation (PQPMI).

    NewWave has several contracts with CMS, including the Chronic Conditions Warehouse and Virtual Resource Data Center contracts. It is also the incumbent contractor for the CMS Enterprise Privacy Policy Engine.

    Two interesting items have come up regarding this. In the informal review process, we learned that the NewWave data processing platform uses the provider specialty off the National Plan and Provider Enumeration System (NPPES) (specialties are called “taxonomy” in this system) to determine the inclusion of that specialty to the PQRS program. Our clients often have differences between the PECOS and NPPES data, and for 2015 we had several instances in which the NPI taxonomy was not updated to reflect subsequent state licensure. Thus, our biggest advice in 2016-2017 for all professionals is to double-check your information in both systems for accuracy and consistency.

    Another concern is that NewWave doesn’t have access to the other reports available on the portal.cms.gov system. Basically, the two contractors administering the very related programs of PQRS and VBM can’t see each other’s reports. So far, we have had several instances where the PQRS feedback report didn’t match the Quality and Resource Use Report (QRUR) Table 7 Individual Eligible Professional Performance on the 2015 PQRS Measures.
  • Physician Quality Reporting System and Electronic Prescribing Incentive Program Data Assessment, Accuracy, and Improper Payments Identification System Contract – The 2013 award went to Arch Systems, Inc. (among other subcontractors for support of the contracts listed here). Arch is tasked with identifying gaps, data errors, and inconsistencies on how program data is being procured, translated, transmitted, and submitted to the PQRS and eRx incentive programs by registries and GPROs; validating and verifying the accuracy of GPRO and registry data submitted by or on behalf of eligible professionals; and supporting the development and implementation of a process to identify PQRS and eRx improper payments derived from registry and GPRO data.

    These will be the audit watchdogs that we likely will see more from as the program matures in 2016. We look forward to working with them in a more public role.

  • DECC (Computer Science Corporation, ViPS/General Dynamics Information Technology and 2020 – Business Integra) – This large collaboration is the IT backbone for the quality reporting programs. Noted in the contract these contractors (main awardee is Computer Sciences Corporation) under the Development Effort Consolidation Contract (DECC) is to consolidate and innovate four stovepipe applications onto the Oracle platform. The four applications we know and dislike are Hospital Reporting, Physician Quality Reporting System, End-Stage Renal Disease and Quality Improvement Organizations.

    Users already are experiencing some system pinches with these platforms as the consolidation and innovations move forward. A goal in this area is to have more frequent back-and-forth discussions between developers and system users. Personally, I look forward to more API integrations and the movement away from manual uploads of data.
  • Registration and Attestation System (R&A) – This is the meaningful use attestation site used by CMS and states for their Medicaid incentive programs. It’s currently unclear, but this federal contract may have been awarded to Xerox which provided states access to their own systems.

    The already bloated list of contractors is complicated by the integration of this system and its program into MIPS. Maybe the R&A will be added to the DECC?
  • CAHPS for PQRS Data Team (RAND Survey Research Group) – New this year, and buried in my spam folder, is the Rand Corporation taking over the reins and registration site for group practices’ and Accountable Care Organizations’ reporting data on patient satisfaction through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey-certified vendors.

    Despite the fact that PQRSCAHPS.org is hosted by QualityNet, the helpdesk this fall, even on the deadline day for specifying the chosen CAHPS vendor (Sept. 20, 2016), they didn’t know about the deadline or to whom to get the information. I was told that a different unit had that information and that the main line couldn’t help me. After separately reaching out to that unit (This email address is being protected from spambots. You need JavaScript enabled to view it.), I learned that an email was sent to the large GPRO organizations giving them information about the new RAND hosted portal https://cahpsportal.rand.org/. Thankfully, the invitation was dug out of the spam and everything was met on deadline. Imagine the number of folks who didn’t follow this route.


With this many actors and hands in the cookie jar can be messy, I can only think of President Eisenhower’s famous quote about the dangers of a military industrial complex. We are in the age of the healthcare industrial complex. We must be aware of the many actors that are outside the government and demand for timely, accurate answers regarding these public programs.

A few key tips to keep in mind:

  • Email your inquires about 2016 quality reporting to This email address is being protected from spambots. You need JavaScript enabled to view it..
  • Keep electronic and paper copies of all correspondence in cases of audits for 5-7 years, based upon your document retention policies.
  • Where possible, help the QualityNet Help Desk route your question to the appropriate contractor by naming the contractor (or acronym) for your question.
  • If you haven’t already, double-check both your NPPES and PECOS files for accuracy, especially on the listed specialty/taxonomy for each of your clinicians. Each specialty/taxonomy listed first is the one that counts for these programs.
  • If you are reporting data to CMS via a vendor (registry, QCDR or EMR), call your vendor and find out more about what data is being submitted and the timeline. While data is required by March 31, the government does allow data to be overwritten if you find errors. Work with your vendor to get data in early, and double-check exactly what they send. We had a caller show us that for their specialty physicians, they submitted data on dental measures because their EMR system collected the data. They were considered poor performers because the measures were reported without their specific knowledge.
  • Stay on top of your deadlines. For inquiries and help, anticipate seven or more business days for response. Plan to get information into the appropriate vendor two weeks ahead of deadline.
  • Comments are due on MIPS by 5 p.m. on Dec. 19. Submit comments through Regulations.gov by searching CMS-5517-FC to find the correct regulation. 

About the Author

Jennifer Searfoss is the founder and chief solutions strategist at SCG Health, LLC, a boutique value improvement organization focused on creating value in healthcare through workflow optimization, revenue cycle management, and strategic planning in this post-health reform industry environment.

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Last modified on Wednesday, 14 December 2016 05:20

Jennifer is the Founder and CEO of SCG Health. Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.