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A Contrarian view on MIPS

January 1 will not be as hard as you may think. In spite of all the pages of regulations, MIPS is not all that different, really. At least based on the Proposed Rule. Of course the new Final Rule with its thousands of pages may paint a different picture, by the time we absorb it all. But in general CMS does not originate new content in a Final Rule, that was not present in a Proposed Rule.

Underneath all the MIPS language, we remain with Meaningful Use and PQRS, which we have been doing for years. Add in Clinical Practice Improvement Activities, a dramatically simple compliance process, and January 1 does not seem all that daunting.

In fact, the "Meaningful Use" component gets easier, at least for the sophisticated players already in Stage 2 and eyeballing Stage 3. The new rules require a smaller set of compliance metrics than what we were all planning for. The "PQRS" component gets reduced as well, from 9 measures to 6 (for providers outside an ACO).

The biggest change from Meaningful Use and PQRS to MIPS falls in how the overall score is calculated, and how overall reimbursement is determined. Doing those two things may actually require that providers build (or buy) new software that operationalizes the thousands of pages of rules.

So as you read the new Final Rule that goes into effect in January, prepare for a series of long sessions. But Don't Panic! And if you need some of that MIPS rule-taming software, check out our MIPS Monitor. It will make you a hero, and save many weeks' worth of your personal effort.

Director Slavitt's Unintended Consequences on MIPS Flexibility

There is an unintended consequence, and perhaps a great windfall for those who pay attention

Recently CMS Acting Director Andy Slavitt published a blog entry that gives a peek into CMS intent to provide flexibility for providers concerned over the aggressive timetable for MIPS Rollout in 2017. Although details will not be forthcoming until the Final Rule is published in November, all the articles, blogs and tweets have expressed appreciation for the ability to defer participation in MIPS. That "deferral" could take the form of either partial year participation for a reduced payment adjustment, or a partial data submission designed to avoid penalties.

Here is the unintended consequence, and potential windfall ...

Start with the reminder that MIPS is a competition. Those providers with low scores relative to the national average pay a penalty. That penalty is used to fund positive Medicare adjustments to those providers with high relative scores. Now consider Director Slavitt's two flexibility options:

Option 1: As long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment.

Option 2: You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment.

If you are wondering about more details, then you need to wait until the Final Rule is published in November.

Now let's think about what might happen under Director Slavitt's flexibility options if a large number of low scoring providers take themselves out of the pool with one of these options. As a result, the remaining pool of full MIPS participants only contain high scoring providers. Based on the way MIPS scores and payments are calculated, the lowest tier of these high scoring providers will pay the penalties to fund their highest scoring colleagues. Interesting, yes?

More interesting is the next wave of logic. As provider management teams anticipate the above scenario, even those providers with the potential to score well could elect to take the "no penalty" option and wait for a later year in which the playing field is again level with a broad population of competitors. The net effect could well be a de-facto deferral of MIPS / MACRA for 2017 for all but the very best competitors.

Here is the takeaway: You can either take one of the above "safe" routes and minimize your data submission efforts or if you decide to play, make sure your scores are well optimized for MIPS. The toughest and most successful competitors will develop breakout strategies that involve detailed analysis of their options, and detailed configuration of their submissions. These analyses, and submission strategies will stretch the capabilities of spreadsheets and manual techniques. The best way to succeed will be the employment of software designed just for the purpose of MIPS Optimization.

But ... and here is the home run ... for those who optimize and score well, remember the Bonus Pool that CMS has set aside is $500,000,000 to be spread across the top tier performers. And if the size of the overall pool is diminished by Director Slavitt's flexibility options, that pool is spread across a smaller number of participants. So soon, you need to decide your MIPS Strategy.

Will you choose to "sit out a round", or "seize the day"?

Ugh. MIPS Means Dual Attestation for Some Providers

Meaningful Use Medicaid Providers who also have Medicare Billings ...

Here is an interesting question we just researched from a community member of our MIPS Preparation Portal:

"I know that MIPS specifically excludes Medicaid, but what about my Meaningful Use Medicaid providers who also have Medicare Billings?"

This appears to be one of those Unintended Consequences that pop up in big regulations.

We looked closely and could find no explicit language addressing this issue. So providers are left with following the basic guidelines of both programs. Here is how it breaks down:

1. Meaningful Use Medicaid providers will have to attest with their individual states, as long as they are receiving stimulus payments. Once a provider's stimulus payment stream has been exhausted, the only reason to attest would be to protect any Medicare billings from Meaningful Use Penalties. Since those penalties go away after 2018 due to MIPS, State-level attestation can eventually go away.
2. Any provider who has Medicare Billings above a $10,000 threshold must comply with MIPS, which includes Meaningful Use Attestation.

So, it looks like some of us might need to Attest twice, unless CMS puts something into the Final Rule in November, accepting a "feed" from States. However, since the data States currently provide to CMS does not include detail numerators and denominators (which are required to calculate a MU MIPS score), dual attestation is a likely option.

Join our MIPS Preparation Portal here. You will find a number of useful downloads, and enable free access to our expert staff who can research the regulations on your behalf for answers to all your MIPS questions.

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MIPS for ACOs - free downloadable briefing

Ok, so you are pretty sure you don't have an Advanced APM because your physicians don't accept Capitations. But what is the impact of being an ACO under MIPS?

Quick 9 slide synopsis ...

It is an easy download, part of our ongoing series of useful MIPS tools.
Download our MIPS for APM slide deck here (sorry for the ugly URL).

https://sr131.infusionsoft.com/app/page/42c9157589c319dcbbb230900d070d7d?inf_contact_key=cef4b7f06d33df82e6ab49fba40f991e

Once you download, the content takes all of 15 minutes to absorb with definitive answers, and links to detail citations that will quickly make you an expert.

Is CMS driving Quality Software vendors out of business?

When CMS rewards EHR-based Quality reporting, what is the role of existing Quality Software?

In the MIPS Final Rule, CMS points out the legislative direction received from congress to encourage adoption of the new QCDR participation. And in fact, CMS does so.

But ...

The "encouragement" is limited to providing one or two CPIA (Clinical Practice Improvement Activities) as a reward. This appears to be a hollow encouragement, given the ease with which providers can comply with CPIA apart from Quality. See our blog on the topic, titled "CPIA looks deceptively simple. What's the catch?"

There is a bigger incentive, on a different Quality Submission method, which could open the door to easier, competing options. CMS is encouraging "End to End CEHRT" submission, by providing bonus points to providers selecting this technique. Remember in a prior article how we identified Quality as the biggest differentiator? In essence, extra points on Quality can boost a provider ahead of competitors for MIPS Funding more decisively than any other category scoring.

End to End CEHRT Submission requires that Qualilty data is obtained from CEHRT using ONC Adopted Standaards, and the Qualified Registry, QCDR or other HIT vendor electronically performs aggregation, calculation, filtering and reporting. This sets up creation of CQM data without human intervention, based completely on EHR data.

Potentially, this seems to qualify all methods for End to End CEHRT. However, in those cases where CEHRT data is good enough to qualify for the end to end bonus, what is the "value added" of additional (QCDR or Registry) software tools? Under the new regulations, providers could simply submit data directly from CEHRT, similar to current Meaningful Use Batch Attestation.

It begs a new question. If Quality data can be submitted from EHR directly, what is the value of big investments in third party software that reads cllinical data to create CQM content just to send off to CMS, or to a registry?

Download our annotated copy of the MIPS Rule, and navigate to page 28256, where this topic is clearly highlighted. Then start analyzing your own expenditures on CQM generation tools.

MIPS ACOs could be sending money from North to South

Regulations sometimes result in Unexpected Consequences. Here's one.

First, recall two key background facts:

MIPS Creates Competition. Your MIPS reimbursement depends on how you score against a broad peer group (i.e., All ACOs are compared against each other, and high scoring ACOs get the money that low scoring ACOs pay in penalties).

Quality is the biggest differentiator. Your score on Quality contributes at least as much to your overall MIPS Score, as all other measures combined. In fact, it is likely be be more impactful than its 50% weighting factor implies. See our blog entry here for an explanation.

Here is the scenario under which MIPS money moves from Winter climates to Summer Climates. It starts with the rules under which ACOs submit their Quality Measures, using CMS Web Interface. This method (required for ACOs), always uses the first 284 Medicare patient encounters of the year. Let's assume those patient visits occur in January and February.

If you live in Florida, or Arizona you know about a phenomenon that happens around January (give or take a month) of each year. Affluent and healthy retirees (Medicare Recipients, all) go south for the winter, leaving a sort of "adverse selection" behind of those who are too ill or less affluent.

So think about the impact on CQM scores. Providers in Winter climates have their healthiest patients pulled from the population. Their CQM scores are likely to be lower in January and February than later in the year. With lower CQM scores, come lower MIPS scores ... and reduced MIPS Adjustments.

Interesting, isn't it? I would like to credit this observation to Nancy Schlichting, CEO of Henry Ford Medical Systems in a letter she posted to CMS commenting on the MIPS Proposed Rule. Thank you, Ms. Schlichting.

Do you find these posts interesting?  Register Here to subscribe to our ongoing MIPS Newsletter.  

 

MIPS Quality Management will Change your World

Your MIPS Composite Score will be more influenced by Quality Reporting than anything else.  First of all, the Quality Category counts as much as all three other categories combined.  Second, it will be the hardest to score well at.  Here’s my thinking:  

1. Those of us already doing Meaningful Use should score very high – with a lot of 100% achievers, mainly because that is the standard we have already been meeting, and for 2017, not that much is new.
2. CPIA is a lay-down-hand. With all the choices, and the low scoring bar, most should score 100% on this category as well.
3. Cost could be a big variable, but only accounts for 10%. You could totally fail Cost and still score a composite 90%. 
4. Quality is no longer a pass-fail function. Your score on Quality will be based on how your staff performs against national benchmarks. CMS will calculate and publish 10 layers (deciles) for each quality measure.  Each quality measure is worth a baseline of either 10 points, or 8.5 points (for “topped-out” measures where everyone already scores very well).  Each EC’s score for each of the 6 measures they select (or 18 measures assigned under your ACO) is ranked into the appropriate decile.  If you are in the third decile, you get 3 (of 10) points.  If you score in the 9^th decile, you get 9 points.  (Lower values if you choose topped-out measures).

You can get a couple bonus points for selecting “high priority” measures, or for submitting your measures using an “end-to-end CEHRT” method. 

At the end, your overall MIPS Quality score is the addition of the individual scores for the measures you choose to submit.   Don’t expect to get 100% … this would require scoring in the top decile on every single quality measure. 

So when it comes to determining what impact MIPS will have on your Medicare reimbursement, the most important person in your organization will be those individuals who can most effectively analyze, select, and optimize your Quality Scores.  Whoever does best on Quality … takes Money away from those who do poorly on Quality.  It’s that simple. 

CPIA Looks Deceptively Simple. What’s the Catch?

Most of MIPS already exists. We already attest Meaningful Use and file our PQRS data. CMS calculates Value Based scores from claims and PQRS submissions, making VBM administratively simple.

The new content is CPIA (Clinical Practice Improvement Activity). The title makes us think that CPIA has the potential to be pretty intrusive, and is on the surface, worrisome. But on second take, the list of Activities from which we can choose is long (94 items), and we only need select a few. Scoring is simple, too. A single item is worth either 10 or 20 points, and most of us will need 60 points for a perfect score, and 30 points for partial credit. There are some complex rules granting relief for special cases of EC’s (Eligible Clinicians), but face it … only 60 points total?? Piece of cake.

What is even easier, is that many of the Activities are probably things we already do. Just pick a couple of those …

So why do I worry? Well, CMS has stated that MIPS in general and CPIA particularly will become “increasingly more stringent over time” (Page 28213, Proposed Rule). And there is a formal process for adding increasingly more CPIA activities. Why would it be necessary to add more activities, when we currently only need to score 60 points out of a possible 1,050? I’m guessing the second time around, will be harder.

To score yourself, we have created a simple spreadsheet with all the activities. Simply identify which work for your EC’s and the tool will calculate a score for you.

Download the tool here

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You can influence the MIPS Final Rule, more than you might think

I recently posted a couple suggestions to CMS on their website for the MIPS Proposed Rule. In the process, I was able to scan the universe of comments left by other people. You can view - and post - comments here until June 27:

https://www.regulations.gov/#!docketDetail;D=CMS-2016-0060

As a member of the community of professionals reacting to the MIPS Proposed Rule, I was disappointed in the quality of "comments" I saw. All in, there are fewer than 500 comments. While a handful (perhaps 10%) were thoughtful, insightful, or posed serious questions, the majority were pejorative rants not pertinent to actions CMS is able to take. Entertaining, perhaps ... but not especially useful.

The intent of the comment and review process is to provide feedback to CMS that will avoid or mitigate unexpected consequences, indicate support for valuable concepts, and in general to improve our experience with this inevitable body of regulation when it goes effect in 2017.

If you are concerned, join the small group who has voiced questions or "answerable" concerns with comment on the above link. It is easy and given the small volume of comments to date, you are likely to have an impact on the MIPS regulations!

If you need a better way to review the Proposed Rule, take a look at our annotated version, which you can download for free here:

http://www.meaningfulusemonitor.com/mips-education.html

CMS may drive you to change your PQRS vendor

In the MIPS Proposed Rule, CMS says they are considering a requirement that all MIPS vendors be capable of submitting three of four MIPS Categories. Your current PQRS vendor does not do this yet, and the addition is a big deal.

In today's market a large number of vendors providing PQRS capabilities, under QCDR, Qualified Registry, EHR Direct Submission, or EHR Submission Vendor. Most physicians use one of these vendors to avoid the PQRS penalty for non-filing, either directly or through an ACO.

For Meaningful Use, most physicians currently submit attestations manually on the CMS Website. There are a small handful of vendors offering electronic submission software, and a small number of provider groups have created "automated batch attestation" interfaces. So far, the vast majority of EP's have their MU attestation submitted manually one at a time on the CMS web site.

If CMS finalizes this proposal, all existing PQRS vendors would be required to add the ability to submit their Meaningful Use (Advancing Care Information) measures electronically as well. (And existing Meaningful Use vendors would be required to add PQRS submission capabilities.)

Although the regulations are still in proposed form, it appears that the CPIA (Clinical Practice Improvement Activity) data will take the form of attested values, rather than content extracted from CEHRT.

Bottom line is a good news / bad news scenario. Good news is that CMS may require vendors to build and deploy capabilities you don't yet have, to save some time. Bad news is that you are likely to have to change vendors to take advantage of this capability - and there is not yet a model for evaluating one vendor against another. Stay tuned! Citations on Page 28183 of the MIPS Proposed Rule

To see this content highlighted, download our free Annotated Version of the Federal Register.

Download at our website for free

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MIPS Required Reading vs Optional vs Don't Bother

About half of the MIPS Proposed Rule is unimportant to most of us

Short answer - to be an expert in MIPS, you only need to read section II.A - II.E. The rest is regulations, Congressional "collection of information" requirements, and background. In a college class, the professor would identify it this way:

1. Executive Summary - Optional. Definitely have your boss read this, but other than creating your personal "elevator speech" on MIPS, you are better off with the details.
2. Section I - Background - Optional. Only 4 pages, but does not provide any operational detail
3. Section II.A - II.E - Required Reading for the 95% of us who will be doing MIPS, rather than APM. Pages 9-133 are well laid out into logical content segments, if you have navigation aids.
4. Section II.F - Only required for the 5% who will be doing APM (if individual physicians have financial risk contracts, such as capitation).
5. Sections III - IV - Intended for policymakers, lawmakers and attorneys. No actionable content exists here, that is not covered in II.A - II.F. If anything, you may elect to share this section with your legal department.

To simplify your reading, download our free Annotated Version of the Federal Register, which highlights these sections.

Download at our website for free

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The most "highlighted" part of my copy of the Federal Register

The good news is that it appears compliance will be a little easier on the EP staff. The other side of the coin is that administrative staff needs to be a bit more knowledgeable, and I don't see a short cut here. You need to read sections II.E.5.h.(1) through II.E.5.h.(15). It covers pages 74-87, and requires an hour or two of quiet time to figure it all out. Here's a couple outline points:

1. MIPS APM = ACO for most of us. There are other types of APM's, and the "MIPS APM" it a slightly different version. (II.E.5.h.(1))
2. MIPS APM does not have to submit Performance Measures! (II.E.5.h.(3))
3. You have to be registered as a MIPS APM - it is not automatic (II.E.5.h.(4))
4. MIPS ACO does not qualify for special reporting in first year (II.E.5.h.(2))

To make your research easier, we have created a free annotated version of the Federal Register. Download at our website.

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Physician Compare goes Public with Details

What effort to put a best foot forward, and verify what gets published?

At some (as yet unspecified) near future date, patients will be able to see detail quality reporting information on every physician in the country. This data will come from your PQRS / MIPS Quality submission, and other submitted MIPS data starting in 2017. For consumers of health care, this could be an exciting nationalized scoreboard by which to select providers of care.

I think this probably drives a bit of extra work for most of us.

The Physician Compare Website will include, in an easily understandable format, all individual and group Clinical Quality Measure (CQM)  scores, MIPS overall scores, and MIPS program element scores. The site will also include aggregate data to be used as benchmarks.

Each EC will have advance notice of what data will be published (30 days). We can file appeals if the data are incorrect. Given the visibility and comparability of the data, it may be prudent to inject a bit of extra diligence in the selection of what Quality Measures each EP submits, and a bit of extra review in making sure CMS is about to publish what was actually submitted.

As we start our budgeting and workload planning for the next fiscal year, it appears MIPS will be driving some extra work.

How your EHR could become De-Certified under MIPS rule

In a prior post, I identified CMS intent to increase the bar for clinical data sharing. Quite frankly, I missed something important. As I read a bit deeper, the possibility emerges that CMS might, under some circumstances de-certify an installed instance of an EHR. Under MIPS, this would result in the loss of Meaningful Use scores, reduce the options available for CQM submission, and invalidate Advanced APM options. Here's the three-step logic chain leading to that conclusion.

• ONC (and by extension, CMS) believes some providers interfere with information exchange - based on an April, 2015 report ONC based on Congressional request. See Page 41, MIPS proposed rule.
• Congress urges ONC to decertify products that block information exchange: Page 41, MIPS proposed rule.
• CMS requires demonstration that provider did not restrict interoperability: Here's the rub. CMS identifies three specific steps of attestation. You are required to attest that you have implemented technologies, standards, policies, practices and agreements ... etc. So, in the event that you have not addressed Direct Messaging, or some other form of interoperability technology, CMS may have the ability (under the new MIPS rule) to do more than simply disallow this one measure. Page 43, MIPS proposed rule.

Of course, we cannot know CMS's intent. All we can know is what they are enabled to do under this rule, and it is a bit chilling.

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MIPS Rule forces new level of Physician data sharing

In my journey through Draft Proposed Rule, I just came across another striking provision. CMS will require us to attest that we have actively supported interoperability, especially with physicians outside our own organization, and with technologies outside our own EHR.

The practicality of this provision will be exposed in FAQs and subsequent rulings - I don't think it is quite clear enough yet. The language of the proposed rule does not state whether simple Direct Messaging is enough, but could be interpreted to imply a requirement for actual interface to Health Exchanges, or to other provider's EHR. Those of us who have attested to interoperability in the past by simply connecting our own hospital to our own EP's might need to expand our connections.

Here are the three broad provisions. See the actual Three part Attestation in the Draft Proposed Rule, on Page 43:

• Provider did not disable functionality: First, the eligible clinician, EP, eligible hospital, or CAH would be required to attest that it did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.
• Provider implemented technologies supporting exchange with unaffiliated providers: Second, the eligible clinician, EP, eligible hospital, or CAH would be required to attest that it implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: connected in accordance with applicable law; compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria; implemented in a manner that allowed for timely access by patients to their electronic health information; (including the ability to view, download, and transmit this information) and implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers, including unaffiliated providers, and with disparate certified EHR technology and vendors.
• Provider responded to requests for information: Third, the eligible clinician, EP, eligible hospital, or CAH would be required to attest that it responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers, and other persons, regardless of the requestor’s affiliation or technology vendor.

CMS Proposes rights to On-Site Surveillance of your EHR!

Ok, if you don't read anything else in the new MIPS proposed rule, read the section (pages 36-41) requiring that we cooperate with CMS Surveillance and Direct Review of CEHRT.  

It proposes that CMS can demand on-site access to your EHR, so they can verify its functionality.  In the process they will have unrestricted access to PHI, without patient authorization and without a BAA.  

This certainly is more intrusive than current CMS audits, and quite likely more time-consuming on part of the provider.  If you feel strongly about this proposal, be sure to submit your comments to CMS before the June 27 deadline.  Proposed ruling allowing CMS onsite access to your doctor's EHR (Page 36)

MIPS Proposed Rule Observations, one at a time

Am I more likely to be covered under APM, or MIPS?  

CMS plans that nany more of us will be paid under  MIPS than under APM (starting in 2019 based on 2017 activity).  

• APM participants: 30k - 90k
• MIPS participants: 687k - 746k

Now I know something new.  Page 17, Draft Proposed Rule

Attest hundreds of EP's in less than one day

It sounds too good to be true.  So, take 90 seconds to view a brief video on how it is done.  Then, for a modest one-time trial fee  you can get all this years' Medicare Attestations done with automated batch submission. You provide only the spreadsheets and reports you already use, and in a day's time you will be submitting automated batch files to CMS for all your Medicare EP's. 

Current customers find savings of hundreds of hours by eliminating all Medicare data entry time.  

If you are not doing this, you are neglecting the opportunity to do your job in the most efficient way. Regardless of your current EHR, or your current processes, the automated link to CMS defines state-of-the-art technology and business processes.  Visit MeaningfulUseMonitor.com for detals.  

 

The Death of Meaningful Use? Not so Fast.

By Jim Tate, EMR Advocate

Meaningful Use Audit Expert

 Twitter: @JimTate, eMail: Inquiry@meaningfuluseaudits.com

Like all great rumors it started with a grain of truth. CMS acting administrator Andy Slavitt, made a statement (“… we’re now in the process of ending meaningful use”…) that took on a life of its own and soon the mole hill became a mountain. In the blink of an eye the word spread that the meaningful use program had died. My inbox was full of emails from providers and vendors asking if their prayers had come true. In a world of social media there was just room for the headline, forget the context. Here are some Tweets we saw this week that added to the confusion. I am not reporting the authors; you know who you are. Suffice to say the quotes below came from a collection of organizations considered the most reputable in the field. The rush to report failed to meet the first rule of journalism, “get it right”.

 

• CMS chief vows to replace meaningful use
• #MeaningfulUse Is Dead, Long Live Something Better!
• CIOs celebrate end to meaningful use
• #EHR #MeaningfulUse to End in 2016, #CMS Leader Says
• #MeaningfulUse ends in 2016, says #CMS – was it worth it?
• Stakeholders Cautiously Optimistic About Plan To End #MeaningfulUse

Every one of those statements is either 100% wrong at worst or misleading at best. Here is what is real:

 The CMS EHR Incentive program, as mandated by law and regulation, is winding down. No surprise there. The Meaningful Use of Certified Electronic Health Records (MU of CEHRT) has been written into stone for the upcoming MIPS program that will affect Medicare Part B in 2019 based on 2017 performance. The failure to achieve MU of CEHRT under that program will cost eligible providers 25 of their maximum 100 composite MIPS scores. The potential loss of revenue dwarfs the current “payment adjustment” under the CMS EHR Incentive Program. The MU concept will pop up in a myriad of ways in the years ahead. The definition of MU and CEHRT will most assuredly be redefined but it is not dead or even suffering from a head cold.

Jim Tate is known as the most experienced authority on the CMS Meaningful Use (MU) audit and appeal process. His unique combination of skills has brought successful outcomes to hospitals at risk of having their CMS EHR incentives recouped. He led the first appeal challenge in the nation for a client hospital that had received a negative audit determination. That appeal was decided in favor of the hospital. He has also been successful in leading the effort to reverse a failed appeal, even after the hospital had received notification of the failure with the statement, “This decision is final and not subject to further appeal”. That “final” decision was reversed in less than a week. If you are a hospital with questions or concerns about the meaningful use audit process, contact him at: audits@emradvocate.com.

 

This article re-posted from HITECH Answers, with permission of Jim Tate

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CMS regulation streamlines Meaningful Use attestation for 2015 reporting year

On December 18, CMS published the electronic specifications for automated attestation to Meaningful Use.   For large provider groups, Automated Attestation can be a huge time saver.  Unfortunately this short time frame does not give many providers enough time to react and build out their own capabilities. 

For interested providers there is an option available from a third party which will allow, for $625, the ability to interface any EHR to CMS, with about a half day's effort on the provider's behalf.  See Meaningful Use Monitor, for more details.  The $625 represents a promotional offer, but is fully functional for this year's attestation.  Seems well worth investigating. 

For regulatory citations supporting this capability, see the following:

Stage 2 Final Rule, Page 54089

"In addition, in lieu of EP-by-EP attestation, we proposed a batch file process for attestation. This batch file process would continue to require that meaningful use measures be assessed at the individual EP, eligible hospital or CAH level. It would be available no later than January 1, 2014. Batch reporting would allow large group practices to submit a large number of attestations at once, while still maintaining individual assessments of meaningful use. We proposed that a batch file process as discussed later would occur through the CMS attestation Web site. Each EP would still meet the required meaningful use thresholds independently; our proposal did not allow the use of group averages or any other method of group demonstration."

2015 Final Rule, Page 62896

"Instead of individual Medicare EP attestation through the CMS Registration and Attestation System, we also proposed to continue the existing optional batch file process for attestation."

 

Automated Meaningful Use Attestation for $625

As we all struggle to react to the late-breaking Final Rule, and react quickly to analyzing readiness, it is hard to think forward to actually attesting.  A month or more of tedium.  Repetition.  Loads of typing and tracking who is done.  Here's a no-brainer alternative:

Meaningful Use Monitor, a premier Meaningful Use tool used by over 5,000 EP's is offering a one-time promotional use of our Automated Batch Attestation, for a single price of only $625.  No strings attached.  

It may sound too good to be true.  But the firm really wants provider groups to experience eliminating an incredible amount of work, while enhancing diligence. Click Here to a page with more details, and we promise you will be the star of your team!  

Getting ready for MU Batch Attestation: No Testing Allowed

CMS encourages batch attestation, but does not provide very much support   

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When we built the Batch Attestation add-on to our Meaningful Use system, we expected a lot of assistance from CMS.  After all, they published it in the Federal Register, dedicated a page on their website to specifications and user manuals, and stated that it was expected to dramatically improve reporting burden.  

 At least, so you might think.  

Truth is, there is not even a test site.  Once you have built an initial file, you have to submit live EP data into the CMS production system to conduct your tests!    

Now, we think we are pretty good system developers and testers.  But what we found was that the specifications were sometimes inconsistent, and sometimes unclear.  And there were a number of undocumented "requirements" that only pop up when you submit.    In spite of our diligence in reading everything multiple times, doing good design, and a lot of "dry run" testing where we would manually review the interface files ... in spite of all that, we ended up with over 20 submissions before the file was correct!  

Take, for instance, the requirement for gathering Vital Signs.  There is not an explicit specification on this topic, nor a clear flow of what CMS expects.  What we found, was that a provider file needed to contain three distinct line items for Vital Signs, even though it is only one measure.  Each line item had to be in the correct sequence, too.  The key was ultimately the definition of exclusions.  Even in the case of providers claiming no exclusions, and fulfilling only the "standard" requirement of height, weight and blood pressure, the input file needed to contain each of the "non-standard" options, with a statement that they were not being applied.  

Working our way through was almost entirely on our own as well.  There is a help line (not dedicated to Batch Attestation, but the overall EHR Incentive Program Help line.  When encountering a production error not covered by the specification, we were required to log a call.  On this system you don't receive call-backs, but you must call in periodically to check your ticket number for a response.  

Here is a good bit of advice, though.  Eventually you will probably get to talk to the Batch Attestation Specialist (at the time we did ours, there was only one!).  Once you have that person, if you keep their name you will probably be able to dial through directly to them.  Save that name!!!  

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use.   

Getting ready for MU Batch Attestation: Create the File

Want some pointers in creating your own Batch Attestation File for Meaningful Use?  Here's the structure your files need to contain ...   

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Eligible Providers can submit either a .csv or .xml file to CMS, containing homogeneous batches of Medicare-eligible providers, in less time than it takes to assemble documentation for even a single manual attestation.   

You will need to construct a multi-tiered file that contains some mandatory components, such as

• Physician Header, containing NPI and other information identifying the EP
• Additional Information, usually a response from CMS;
• Measure Attestations.  The Measure Attestations contain the information you might expect, such as numerator, denominator, and identification of each measure.  Measure identification codes are documented in a spreadsheet you can find on the CMS Meaningful Use Website.  The column layout is, as you might expect, definitively rigid, and some of the column definitions require a bit of head scratching to decipher.  

If you don't have an automated tool that creates these batch files, it is not clear how much time you'll actually save.  This is not a simple spreadsheet dump from your EHR, but a complex file structure requiring specific coded values, within a complex structure.   

Automating the repetitive and error-prone process of individually attesting each EP is worth some effort, though and CMS can definitely accept the input.  No screen-scraper "pseudo-automation" here, but actual interface from one transaction processing system to another.  

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use. 

Getting ready for MU Batch Attestation: Group EP's for efficiency

Think your batch size limit is 1,000 EP's at a time?  Think again ...  you can't include all your EP's in one big batch.     

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There is the first, and most obvious catch.  Batch Attestation of Meaningful Use is only for Medicare.  We continuously monitor individual State Medicaid MU programs, but have yet to find one that has Batch Attestation on their Radar.  We will keep trying, though.   

 Now, for Medicare.  The specifications permit a thousand or more EP's in a single batch. Of course, that is only the upper limit.  As a practical matter, you will have to create and submit multiple batches of EP's, even if everyone is ready all at the same time (unlikely in a 90 day reporting period).  When you submit a batch file to CMS for Meaningful Use Attestation, all the EP's in a batch will need to have similar attributes.  Here's the list:

• Year and Stage
• Home Clinic Address and Tax ID
• Proxy for Attestation
• Mix of Core /  Menu and CQM
• CQM e-filing Method
• Reporting period

 Your "batch management" tools should help align EP's into batches, track progress by batch, and help identify un-batched EP's for later submission.  It is a little extra work, but still orders of magnitude less work than the old, one-at-a-time fill out the CMS website process! 

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use. 

Getting ready for MU Batch Attestation: Rules and Regulations

Curious on the CMS stance for Meaningful Use Group (Batch) attestation?  They have mentioned it in at least two separate Federal Register editions so far, and published multiple additional "rules". 

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CMS has been under some pressure to reduce the administrative effort surrounding Meaningful Use for a while now.  Probably the biggest administrative effort for large physician groups is the simple process of attestation.  It happens all at once, within a short window, and the whole country is trying to access the same website at the same time.   

In April of 2014, we saw an announcement on the EHR Incentives home page regarding batch attestation for eligible hospitals and eligible physicians.  While automated attestation for hospitals does not provide much in the way of efficiency, batch attestation for physicians provides efficiencies of 100:1 or better.  

Batch reporting represents a large benefit to providers capable of executing this technology.  According to the NPRM discussing 2015 - 2017 changes to Meaningful Use, CMS estimates: "that the policies contained herein, once finalized, would result in an overall reduction in the reporting burden for providers of 1.45 hours to 1.9 hours for EPs".  While the technology is not as simple as one might imagine, the business principles outlined in the Stage 2 Final Rule are straight-forward: 

• Quality Measures excluded: Group reporting  is limited to data for the core and menu objectives and does not include the reporting of clinical quality measures, which is also required to demonstrate meaningful use and receive an EHR incentive payment. Clinical quality measures must be reported separately through other electronic submission options.  However, EPs will not have to report core and menu objective data in the same EHR Incentive Group as they report clinical quality measures.  
• Medicare only via the CMS site; 
• Medicaid: states would have the option, but not be required to, offer batch reporting of meaningful use data for Medicaid EP
• Group Size can be from 2 - 1,000 EP's in a single batch and multiple batches per day are permitted.

NPRM for 2015-2017 maintains commitement to Batch: "We are proposing to continue the existing optional batch file process for attestation in lieu of individual Medicare EP attestation through our registration and attestion system. This batch reporting process ensures that meaningful use of certified EHR technology continues to be measured at the individual level, while promoting efficiencies for group practices that must submit attestations on large groups of individuals ... Therefore, in this proposed rule, we estimate that the policies contained herein, once finalized, would result in an overall reduction in the reporting burden for providers of 1.45 hours to 1.9 hours for EPs"

On the practical side, someone must build the batches for submission.  CMS has not required EHR technology to be capable of Batch Attestation, and by all language it is still optional.  Providers can (and most do!) still attest manually.  

As a matter of process (outside the publication of Federal Register content), batches must be fairly homogeneous, consisting of physicians with similar characteristics, such as Stage, Year, mix of measures, address, Tax ID and a common named individual capable of submitting attestation data.  

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use.

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Getting Ready for Batch Attestation? WIIFM?

Modified Stage 2: Practical Implications

Getting Ready for Batch Attestation? WIIFM?

What's In It For Me?  Is this just CMS creating something that won't really make a difference, or who can benefit??   

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Face it.  CMS is under some pressure on Meaningful Use.  Every time they publish a statement of position, they get thumped by CHIME, AHA, MGMA or some other industry group pointing out the reporting burden, or difficulty of achieving measures.  

 

So now they came out with something called Batch Attestation.  It is supposed to help reduce the reporting burden.  But who really benefits?   

Here is who does not benefit.  Hospitals attestation is pretty simple, even though it is manual.  Physicians and other EP's on Medicaid cannot attest via batch (unless their State offers automation - more on this in an upcoming newsletter topic, as we survey the States).  And if you have a small clinic with only a dozen or so providers, the benefit is minimal.  

BUT ... Larger physician groups with significant Medicare participants ... well, that is another story!  In less than the time it takes to attest for a single EP, a MU coordinator can submit a batch with dozens (or more) of attestations all in one quick step.  And if you have a tool that automates the batch creation process, file creation, and response management, you can save months of time using automated Batch Attestation. That's a pretty big WIIFM!  

Now, all you need is to figure out how to build it.  Keep an eye or this blog for some ideas on that.  

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the  Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use. 

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Modified Stage 2: Practical Implications

How should MU Coordinators be planning for Modified Stage 2, once the comment period is closed?  

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The period for public comment on the Notice of Proposed Rule Making for Meaningful Use changes in 2015 - 2017 closes as of June 15. I would anticipate CMS to take 30-60 days to absorb and respond to comments with a Final Rule, which would probably have a short time to “effective date”. 

While we wait, what planning activities should we consider?  It does appear that if changes to Measures are approved for 2015, those changes are likely to be optional, and are described as “Modified Stage 2” measures.  The Modifications proposed would eliminate some measures CMS describes as  topped out, meaning that most providers are already far above thresholds and continuing to track them would be pointless.  

Additional Modifications tend to involve some level of relaxing existing measure thresholds or definitions in some way.  

Practical Implications fall into two categories, your own practices, and those of your EHR Vendor. Analyzing a new set of reports for Modified Stage 2 would be a short learning curve and not too much work across your EP’s. It is a pretty simple change for our Meaningful Use Monitor clients, but a bigger change for EHR vendors, who will have to re-build reports.  I believe it is likely that some vendors may not be able to deploy the new reporting across their entire client base yet this calendar year.  Certainly the Modified Stage 2 regulations are a lot less effort for the vendors than what was the 2014 Edition EHR, but even so ... doing a modestly sized activity across every client could still be a big job for some vendors.   

If your EP’s are able to meet the existing Stage 1 and Stage 2 values for 2015 there would be little or no impact to you, regardless of whether your EHR vendor(s) deploy reports in a timely fashion.  

In fact, waiting on a vendor to deploy any new reports in support of Modified Stage 2 may not be the best choice.  If CMS opens up their website to accept 90 day attestations prior to year end, then you may be able to accelerate some cash flow by attesting any EP’s currently compliant.  

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 Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   And be sure to download the  Meaningful Use Manifesto for a summary of Best Practices around the job of administering and defending Meaningful Use.

The Meaningful Use Manifesto: Collection of Best Practices

Did you value our Audit Best Practices Newsletter Series?  Then be sure to download, view and share the Meaningful Use Manifesto.  We wrote it for your CFO, CIO and Compliance Executives.  

Over the past year or so, we have accumulated a series of best practices for Meaningful Use audit, compliance management, and workflow simplification.  Then we assembled all of it into an e-book (don't panic, it only takes about an hour to read the whole thing), and deployed it for FREE on our website.  Here is the URL for the download page: 

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MeaningfulUseMonitor.com/MU_E-Book.html

We even describe some of our competitor's products here, so you can be assured it is not a direct advertisement, but is truly intended as  a job aid for Meaningful Use.  Take a look and let us know what you think of it ... better yet, let us know what we missed and should have incorporated into it!  

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Of course, the best option is Meaningful Use Monitor - the middleware between EHR, Quality Reporting  - and CMS!   Check out  MeaningfulUseMonitor.com  and start saving time.  

Meaningful Use Best Practice: #19 – Managing Attestation Batches

Thinking about building your own spreadsheet for CMS Batch Attestation?    

There is more to the CMS Batch Attestation program, than simply submitting a spreadsheet with your measures.        

Data not in your EHR: One of our prior newsletters listed the data elements that CMS requires, which are not typically contained in CEHRT products.  It would be simple enough, but these data often vary by provider, or measure, or even by year.  One practicality is that using spreadsheets (rather than a database) will  require a lot of manual effort to page through groups of information in order to decide which supplemental values fit where.   

Managing Attestation Statuses: Once a batch has been submitted, and CMS responds, you'll need a process to update individual EPs within each batch who have "passed" and those who have "failed", and group by remediation steps (including re-submission).  

Organizing Providers into Batches:  CMS requires homogeneity within a given batch.  You certainly can't mix Stage 1 and Stage 2 EP's, and probably can't mix years, either.  You'll also have to group attestations by "like" combinations of measures within each batch.  A downside to doing this with spreadsheets, rather than a database, is keeping track of which EP is in which batch, and which batch type.    

Testing the process:  CMS does not have a test site!  Your first submission will be using live data, to the live attestation site. 

Bottom Line:  Spreadsheets are great tools for analysis, ad-hoc reporting, and one-time processes.  But something like Batch Attestation for large groups of providers feels to us like a database process, for a lot of good reasons.  One excellent solution is Meaningful Use Monitor a comprehensive database compliance tool. MUM interfaces to your EHR and Practice Management System...if you decide to build your own make sure it does the same. 

Also consider the time involved in this process if you decide to do it yourself.  Our cost-effective tool saves time, money and your sanity.  

And keep in touch with our newsletters ... we will share observations as we gain experiences on this potent tool from CMS.   

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Meaningful Use Best Practice: #18 – Your Meaningful Use Coordinator Can't Change Jobs

Ok, it is not really a best practice.  In fact, it is a problem CIO's need to address.  

Here's the problem.  If a Meaningful Use Coordinator is the only person who knows how to find everything related to last year's attestation, then how can you promote that internal employee (or wrap up that consulting engagement)?      

We recently helped a hospital respond to a Meaningful Use Audit by Figliozzi & Company.  The audit was for an attestation from two years ago, when the hospital was just getting started with Meaningful Use.     

At that time, the hospital had engaged an expert in Meaningful Use to educate the clinical staff, coordinate reporting and file the attestations.  She did a good job, and when she left, everyone appreciated her expertise.  Then came the audit request (more than two years after the consultant was gone).    

The consultant turned out to be the only person who knew what documentation was available, what menu items had been attested, where the documentation was stored, and how to respond to Figliozzi. The CIO later commented that they had been fortunate that the consultant happened to be between engagements, and was available on a moment's notice to come in and respond to the auditors.  

"We should have had a simple, common repository with all our Meaningful Use content, and notes" he said.  "At the time, we thought that once we achieved Stage 1, we were good until Stage 2 came around". 

Operationalizing Meaningful Use involves more than clinical procedures and implementing the most current EHR product.   Don't hamper your Meaningful Use Coordinator's promotability by creating a reliance on his or her personal knowledge to support your next five to ten years' Meaningful Use activities.  Treat this job just like you treat important financial or clinical processes, with job descriptions, process maps, and cross training of fallback staff. 

And be certain to use a long-term compliance documentation database for storing these documents.  The audit "tail" is six years long.  One good documentation solution would be Meaningful Use Monitor, but if you don't have that, please make sure to build your own!  This stuff is too important to be left laying around, uncontrolled.