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November Hot Topics, 2017

It is hard to believe that 2017 is almost over! With our practices as busy as ever, the TSI Healthcare Quality Program Services team wants to make you aware of some upcoming deadlines & important news relating to CMS programs. If you have any questions about the items addressed below, please open a ticket with helpdesk@tsihealthcare.com and a member of our team will contact you.

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QP Services Category for This Month’s Call: Quality
Your November QP Services call will be focused on the Quality category. This reporting category is worth 60% of your MIPS Composite Performance Score (CPS). The following will be discussed during your call:

1. Quality reporting documentation
2. Determine and finalize reporting period for Quality category, if applicable

The Remaining Content is Available Exclusively to Quality Program Services Clients.

Your QP Specialist will provide an in-depth review of your performance for the Quality category during your November QP Services call.

Please note, monthly QP Services calls are available exclusively for
QP Services members. 

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Quality Program Services Webinars

Did you miss a Quality Program Services webinar? Don’t worry! The recording and slides from each webinar, available exclusively for Quality Program Services members, can be found on QP Central. 

Previous Webinars:

• October Hot Topics: Under the “Previous Hot Topics” tab in the “Informational Webinars” section.
• Under the “Workflow Workshops” tab in the Quality Category, you will find the following workflow workshops held in October:
  • Adult Kidney Disease
  • Inflammatory Kidney Disease 

Upcoming Webinars: 

• November Hot Topics: November 17

You can register for our upcoming Hot Topics, Workflow Workshops, and MIPS Category Webinars in the “Upcoming Informational Webinars” section of QP Central. ​​​

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Preparing for Your Pre-Attestation Call

Before your pre-attestation call with your QP Specialist, please review the items listed blow for each MIPS Category to ensure you are prepared for the call.

• Overall MIPS Considerations
  • Have you confirmed whether the practice is reporting as Individuals or as a Group?
    • You have until the end of the reporting year to determine how your practice would like to report. However, this is something you should start thinking about now if you have not already made this determination.

The Remaining Content is Available Exclusively to Quality Program Services Clients.

Advancing Care Information (ACI) Category

• Have all test patients been excluded in HQM? 
  • If not, please exclude all test patients by:
    • Logging into HQM
    • Clicking Config 
    • Exclude Test Patients
    • Type in the person number and clicking exclude
• Has your HQM business schedule been updated?
  • If not, please update your business schedule in HQM to reflect the days your practice was closed and no patients were seen.
  • You can do so by:
    • Logging into  HQM 
    • Clicking Config 
    • Clicking MU Settings
    • Clicking Business Schedule
    • Click through each month and click on the day of the month when the practice
      was closed 
• Has your practice completed or have a process in place to complete your Security & Risk Analysis by December 31^st?
  • This must be completed by December 31^st 2017
  • Please visit QP Central for CMS resources to assist you in completing your Security &
    Risk Analysis
• Have you reviewed your ACI reports to ensure accuracy of your denominator?
  • If you have not chosen an ACI reporting period and reviewed your denominators with your QP Specialist, then when running your ACI reports, please check that the denominators look accurate
  • If not, then on your next QP check-in call, please discuss your ACI denominators with your QP specialist
• Have you taken Before, During and After screenshots?
  • If you haven’t selected your ACI reporting period, then you have the option to use the last 90 days of the reporting year
    • Take your “during” screenshots for this category between now and the end of December 31^st
• Have you confirmed the submission method of ACI data?
  • You can choose to submit your ACI data through one of the following methods:
    • NextGen HQM Module
    • Registry (i.e. RISE, IRIS, AQUA)
    • CMS Web Interface

The Remaining Content is Available Exclusively to Quality Program Services Clients.

• If you have locked down your reporting period for any of the MIPS categories above, your denominators should have been confirmed on your QP check-in call. If not, this will be covered on your pre-attestation check-in call.

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2016 Quality and Resources Use Reports are Now Available

A Quality and Resources Use Reports (QRUR) analysis is included in the full QP Services subscription to help practices plan for the Cost category of MIPS. Our QP Services team is proactively preparing for completing practices’ QRUR analysis. 

The Remaining Content is Available Exclusively to Quality Program Services Clients.

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2016 PQRS Informal Review

Individuals and groups that received a 2016 penalty from their PQRS and/or Values Based Modifier performance can request an informal review if they believe their negative adjustment was in error.

• How do you know if your practice received a 2016 penalty?
  • Practices can download their 2016 Quality and Resource Use Report (QRUR) and PQRS Feedback report from the CMS Portal here.
  • These reports show your practice’s performance on both the Values Based Modifier and PQRS programs and any negative or positive payment adjustments.
  • If you have questions about downloading these reports, please open a ticket with helpdesk@tsihealthcare.com.
• Informal Review Requests must be completed by December 1^st, 2017
  • Informal Review Requests can be completed here.

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Documentation for Your MIPS Audit Binder

As QP Service clients have been reminded on each QP check-in call, practices should be keeping a binder of all important documents from the 2017 reporting period.

• Security & Risk Analysis
  • It remains the responsibility of your practice to complete and update a Security & Risk Analysis by December 31, 2017. 
  • If your practice has completed a Security & Risk Analysis in the past, then there is no need to start from scratch this year.
    • This includes any changes to your practice’s electronic systems, reviewing and updating the prior analysis for changes in risks, etc.
  • Please keep in mind that a checklist will not suffice for the risk analysis requirement.
  • Resources are available on QP Central to assist your practice in completing your Security & Risk Analysis.
• Registry Documentation 
  • Please confirm you have documentation from your registry within the first 60 days of your reporting period.
  • If you find that you do not have documentation from your registry, please contact the registry and inquire about your status.
• MIPS Category Documentation 
  • Please keep all final PDF reports for the Quality and ACI categories and required screenshots for IA and ACI in your MIPS audit binder.
• Other Pertinent Documents
  • If your practice completed a hardship application for providers who were new to Meaningful Use in 2016, you should keep a copy of the hardship application you filed with CMS. 

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Regardless of your QP Services subscription, ​​we offer additional resources
to all of our clients at www.tsihealthcare.com/qpcentral.

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