Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)

Quality Payment Program

2019 Qualified Registry Fact Sheet

Overview

To become a Qualified Registry for the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program, you must self-nominate and successfully complete a qualification process.

When is the self-nomination period?

You can self-nominate from:

September 1 – November 1 of the year prior to the applicable performance period.

Tips for Successful Self-Nomination:

1. To become qualified for a given performance period, the vendor must exist by January 1 of the performance period. For example, to be eligible in the 2019 performance period, the vendor must exist by January 1, 2019.

2. You must provide all required information at the time of self-nomination, via the web-based tool, JIRA: https://oncprojectracking.healthit.gov/support/login.jsp, for CMS review and approval.

3. Self-nomination is an annual process. If you want to qualify as a Qualified Registry, you will need to self-nominate for that year. Qualification and participation in a prior program year does not automatically qualify a vendor for subsequent performance periods. Beginning with the 2019 performance period, a simplified self-nomination process has been implemented to reduce the burden of self-nomination for those existing Qualified Registries that have previously participated in MIPS and are in good standing (not on probation or terminated). The simplified process is available only for existing Qualified Registries in good standing.

The list of vendors that have been qualified to submit data to CMS as a Qualified Registry for purposes of MIPS will be posted on the CMS Quality Payment Program website.

What is a Qualified Registry?

A Qualified Registry is a vendor 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 Qualified Registry to submit data on the selected measures or specialty set of measures they have picked.

What are the requirements to become a Qualified Registry?

1. Participants: You must have at least 25 participants by January 1, 2019. These participants are not required to use the Qualified Registry to report data to CMS, but they must be submitting data to the Qualified Registry for quality improvement. Please note that your system must be implemented and able to accept data should a clinician, group or virtual group wish to submit data on the approved MIPS Quality Measures by January 1, 2019.

2. Certification Statement: During the data submission period, you must certify that data submissions are true, accurate, and complete to the best of your knowledge. If you become aware that any submitted information is not true, accurate, and complete, you will correct such information promptly; and understand that the knowing omission, misrepresentation, or falsification of any submitted information may be punished by criminal, civil, or administrative penalties, including fines, civil damages, and/or imprisonment.

3. Data Submission: You must submit data via a CMS-specified secure method for data submission, such as a defined Quality Payment Program data format. Additional information regarding data submission methodologies can be found in the Developer Tools section of the Resource Section of the Quality Payment Program website: https://qpp.cms.gov/developers.

4. Data Validation Plan: During self-nomination, you must provide information on your process for data validation for individual MIPS eligible clinicians, groups, and virtual groups within a Data Validation Plan. You must provide the following to fulfill the requirements of the Data Validation Plan:

• Name of Qualified Registry

• Process of verifying Quality Payment Program eligibility of MIPS eligible clinicians, groups, and virtual groups.

• Process of verifying accuracy of TIN/NPIs.

• Process of calculating reporting and performance rates.

• Process of verifying that your system will only accept data (for purposes of MIPS) on 2019 MIPS Quality Measures during submission.

• Process used for completion of randomized audit.

• Process used for completion of detailed audit.

5. Data Validation Execution Report: You must execute your 2019 Data Validation Plan and provide us with the results (i.e., Results of the randomized/detailed audits? Were there any calculation issues? If so, why did they occur and what was done to remediate?).

• The 2019 Data Validation Execution Report must be submitted to CMS by May 31, 2020.

• The following items should be addressed in the 2019 Data Validation Execution Report:

  • Name of Registry

  • Results of verifying Quality Payment Program eligibility of MIPS eligible clinicians, groups, and virtual groups (i.e., Were any issues identified with the process to determine if MIPS eligible clinicians, groups, and virtual groups meet the Quality Payment Program eligibility requirements? If so, please provide the details regarding the identified issues and how they were resolved.)

  • Results of verifying accuracy of Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) (i.e., Were any issues identified with the process to verify TINs/NPIs? If so, please provide the details regarding the identified issues and how they were resolved).

  • Results of verifying 2019 MIPS Quality Measures are utilized for submission (i.e., Were any issues identified with verification process to ensure that only 2019 MIPS Quality Measures were submitted? If so, please provide the details regarding the identified issues and how they were resolved).

  • Results of calculating data completeness and performance rates (i.e., Were any issues identified with how the measure specifications (MIPS Quality Measures) were implemented in the system? If so, please provide the details regarding the identified issues and how they were resolved).

  • Results of the randomized audit (i.e., Were there any data issues identified? If so, please provide the details regarding the identified issues).

  • Results of the detailed audit (i.e., Provide the details regarding how the identified data issues from the Randomized Audit were resolved (if applicable)).

For the purposes of Qualified Registry participation, we do not require that you provide a written report on Promoting Interoperability or Improvement Activities, as our primary focus is Quality. However, we encourage Qualified Registries to utilize auditing processes to ensure the accuracy of data submissions under the Promoting Interoperability and Improvement Activities performance categories; As Qualified Registries would have certified, at the time of submission, that all data submitted (across all performance categories) is true, accurate, and complete to the best of their knowledge.

A late submission of your Data Validation Execution Report from your Qualified Registry will be seen as non-compliance with program requirements and may result in probationary status or termination in future program years.

Please note that CMS will provide a specific template for the Data Validation Execution Reports. The Data Validation Execution Report template will be posted on the CMS Quality Payment Program Resource Library.

6. Performance Category Feedback Reports: Provide performance categories feedback at least four times a year for all individual MIPS eligible clinicians:

• CMS does not provide a template for the vendor feedback reports.

• If a dashboard is available to clinicians with real-time feedback, CMS asks that the Qualified Registry emails the clinicians four times per year to remind them the feedback is available.

What information is required to self-nominate?

You must provide the following when you self-nominate:

• Vendor Name

• New or Existing Registry (Approved for a previous year of MIPS and/or Physician Quality Reporting System [PQRS])

• Supported MIPS Quality Measures

• Supported MIPS Performance Categories

• Improvement Activities Supported

• Promoting Interoperability Measures and Objectives Supported

• Performance Period

• Vendor Type

• Data Collection Method

• Method for Verifying TINs and NPIs

• Method for Calculating Performance Rates for Quality Measures (source of clinician’s data)

• Randomized Audit Process

• Data Validation Process

• Ability to Provide Data Validation Plan Results by May 31^st Following the Performance Period (Data Validation Execution Report)

• Reporting Options

• Cost and Services Included in Cost

What data submission functions must a Qualified Registry perform?

A Qualified Registry must perform the following functions related to data submission:

1. Indicate:

• CEHRT data source, if applicable.

• End-to-end electronic reporting, if applicable.

• Performance period start and end dates.

• Reporting on Promoting Interoperability measures and objectives or Improvement Activities, if applicable.

2. Submit:

• Data and results for all your MIPS performance categories.

• Include 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.

• Appropriate IDs for Quality Measures, Promoting Interoperability measures and objectives, and Improvement Activities.

• Measure-level data completeness 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 for data validation.

3. Report on the number of:

• Eligible instances (reporting denominator).

• Times a quality service is performed (performance numerator).

• Times the applicable submission criteria were not met (performance not met).

• Times a performance exclusion occurred (denominator exceptions/exclusions).

4. Verify and maintain eligible clinician information:

• Signed verification of clinician names, contact information, costs charged to clinicians, services provided, MIPS Quality Measures or specialty-specific measure sets (if applicable).

• Business associate agreement(s) with clinicians or groups who provide patient-specific data.

• Ensure the business associate agreement complies with HIPAA Privacy and Security Rules.

• Include disclosure of MIPS quality measure results and data on Medicare and non-Medicare beneficiaries.

• Signed NPI-holder authorization to:

• Submit results and data to CMS for MIPS.

• Certification statement that all data and results submitted to CMS are true, accurate and complete to the best of your knowledge.

5. Comply with:

• Any CMS request to review your submitted data.

• Requirement to participate in the mandatory Qualified Registry kick-off meeting and monthly support calls. Failure to participate in the Qualified Registry kick-off meeting will lead the Qualified Registry to be placed on probation.

• Participation requirements (Data Validation Execution Report, performance feedback, etc.).

• CMS-approved secure method for data submission.

What are the thresholds for data inaccuracies? What are considered data inaccuracies?

If any data inaccuracies affect more than 3% of your total MIPS eligible clinicians, you:

• Will be placed on probation due to your low data quality rating.

• Will have the Qualified Registry posting updated for the performance period to indicate you are on probation.

Data inaccuracies affecting more than 5% of your total MIPS eligible clinicians may lead to you being precluded from participating in the following year.

CMS will evaluate each Quality measure for data completeness and accuracy. The vendor will also attest that the data (Quality Measures, Improvement Activities, and Promoting Interoperability measures and objectives, if applicable) and results submitted are true, accurate and complete.

CMS will determine error rates calculated on data submitted to CMS for MIPS eligible clinicians. CMS will evaluate data inaccuracies including, but not limited to, TIN/NPI mismatches, formatting issues, calculation errors, and data audit discrepancies affecting in excess of three percent of the total number of MIPS eligible clinicians, groups or virtual groups submitted. Examples of such errors include:

• TIN/NPI Issues – Incorrect Tax Identification Numbers (TINs), Incorrect National Provider Identifiers (NPIs), Submission of Group NPIs.

• Formatting Issues – Submitting files with incorrect file formats, Submitting files with incorrect element formats, Failure to update and resubmit rejected files.

• Calculation Issues – Incorrect qualities for measure elements, Incorrect performance rates, Incorrect data completeness rates, Numerators larger than denominators.

• Data Audit Discrepancies – Vendor acknowledgement of data discrepancies found during data validation but not corrected in submissions, Vendor/clinician acknowledgement of data discrepancies found post submission from clinician feedback reports and our Quality Use Resource Use (QURU) reports.

What may cause an approved Qualified Registry to be placed on probation or precluded from the program?

CMS may place Qualified Registries on probation for failing to meet certain standards and/or participation requirements. These requirements include, but are not limited to the following:

• Qualified Registry support call absences,

• Delinquent deliverables like the Data Validation Execution Report, Qualified Posting review and approval,

• Submission of false, inaccurate or incomplete data.

If a Qualified Registry is placed on probation, CMS will require that the Qualified Registry take remedial action by submitting a corrective action plan to address any deficiencies or issues and prevent them from recurring. The corrective action plan must be received by CMS within 14 days from the date of the CMS probation notification for CMS review and approval. Failure to comply with the probation process may lead to termination for the current and/or subsequent performance year.

The Qualified Registry Qualified Posting will be updated to reflect when a Qualified Registry is placed on probation and/or terminated from participating as a Qualified Registry.

CMS may place the Qualified Registry on probation or preclude the Qualified Registry for the current performance year and/or the subsequent performance year, as applicable.

What is the overall process to become a Qualified Registry?

The overall process includes these steps:

• The vendor completes and submits the self-nomination form, supported MIPS Quality Measures, and Data Validation Plan through JIRA for CMS review and approval.

• If the self-nomination form, MIPS Quality Measures, and Data Validation Plan are approved, a Qualified Posting is developed for the Qualified Registry that includes contact information, approved MIPS Quality Measures, performance categories supported, services offered, and costs incurred by clients. All approved Registries are included in the Qualified Posting that is posted on the CMS Quality Payment Program website.

• Approved Qualified Registries are required to support the services and MIPS Quality Measures listed on their Qualified Posting as a condition of participation in MIPS. CMS expects each approved Qualified Registry to support the services and MIPS Quality Measures listed on their Qualified Posting through the entirety of the performance and submission periods for which the Qualified Registry is approved, as well as meet all participation and program requirements. Failure to do so will preclude the Qualified Registry from future participation in MIPS.

Resources

• Qualified Registry Support Calls - CMS will hold mandatory support calls for Qualified Registries that are approved to participate in the performance period they have self-nominated to be considered for. These support calls will be held approximately once a month, with the kick-off meeting being the first of the monthly calls. The support calls address reporting requirements, steps for successful submission, and a question and answer session. Attendance to all support calls is mandatory, and is a requirement of participation as an approved Qualified Registry. Each vendor must attend both the webinar and audio portion via computer or phone to receive credit for attending the support call. One representative, from a vendor supporting multiple Registries, will NOT be counted as attendance for multiple Registries.

• Quality Payment Program ListServ - The Quality Payment Program ListServ will provide news and updates on new resources, website updates, upcoming milestones, deadlines, CMS trainings, and webinars. To subscribe, visit the Quality Payment Program website and select “Subscribe to Updates” at the bottom of the page or in the footer.

• Quality Payment Program Website - Educational documents for Qualified Registry participation will be available on the website to help support you in your submission process.

• Quality Payment Program - If you have questions, the Quality Payment Program is here to help and will be able to direct your call to the appropriate staff to best meet your needs. You can reach the Quality Payment Program at [email protected] or 1-866-288-8292 or 1-877-715-6222 (TTY) Monday – Friday, 8:00 AM – 8:00 PM Eastern Time.

• The Self-Nomination User Guide - This guide provides step-by-step instructions for vendors looking to become a Qualified Registry for the 2019 MIPS performance period.

• QCDR/Registry Google Calendar - Will be used to track and highlight key milestones and activities for the annual self-nomination period.

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