Health care webinar recap: Want to avoid CMS MACRA pitfalls in 2018? Check out 2017 lessons learned

By nThrive | Posted: 06/25/2018

MACRA pitfalls

nThrive’s MACRA* Education webinar in June, “Quality Payment Program Year 1: Lessons Learned,” covered a range of helpful MACRA tips gleaned from real-life 2017 submissions to the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP). Presenter Moshe Starkman, an nThrive Senior Director, Value-based Reimbursements and MACRA subject matter expert, identified key challenges, lessons learned and health care reimbursement solutions organizations can leverage to avoid MACRA pitfalls when reporting 2018 quality scores.

Available On-Demand here, Starkman covered the following key points during the event.

Identify and access data

Topping the list of lessons learned in 2017 is identifying necessary data. “Make sure you know what you have and how to get it,” Starkman said, “as well as how you’ll deliver it.”

He noted that data can be extracted in multiple ways, with the first to capture portable data (CSV, XML, JSON) and load it into an analytics platform for processing and scoring. This can be accomplished internally or through a certified registry.

Second, organizations can capture and score data directly from their electronic health record (EHR) platform, setting up contract monitoring capabilities via a quality revenue cycle dashboard. However, while this is a good approach, Starkman cautioned organizations to be sensitive to the real-time stress this can place on an organization’s EHR system.

“Regardless of the choice, ensuring data accessibility should be any organization’s first priority,” he said.

Set up business-level approvals and IT collaboration

If the industry learned nothing else from the Physician Quality Reporting System (PQRS), which preceded the MACRA ruling, Starkman emphasized it is important to get vendor contracts in place sooner rather than later.

“Very often these decisions are not finalized until late in the year,” he noted, “creating unnecessary strain on everyone involved to prepare for the imminent Q1 submission period.” More importantly, he stressed that waiting until the last minute also significantly reduces an organization’s opportunity to identify and make changes throughout the performance year to improve their overall MIPS or APM reporting position.

“It’s no longer just about reporting your best performing measures,” he explained. “It’s about reporting your most competitive numbers, getting in front of your quality scores early to make necessary adjustments.” He added that although organizations will get feedback from CMS, it comes after-the-fact when it is too late to influence the outcome.

When it comes to getting data, Starkman also cautioned leaning too heavily on internal information technology (IT) resources, which are often focused on maintenance and system upgrades. “Typically their bandwidth is limited and this strategy may add stress and complexity to an organization’s systems. Be sensitive to their concerns and challenges while also stressing that access to a powerful set of analytics tools is mission critical.”

Be prepared for technology bugs and unrefined workflows

In year one, Starkman said bugs and unrefined workflows from CMS’ new software resulted in MIPS data submission delays, frustration and fear on the part of health care providers attempting to submit data.

“The net result is that CMS extended the submission period to give their own support team enough time to address lingering questions and mitigate potential backlash from frustrated users,” he explained. This included changing the API Token received by revenue cycle management vendors, as well as endpoints between testing and live environments, without providing instructive documentation. Eligibility determination also suffered from a limited technology solution, catering to individual providers but not groups of providers, which were unable to determine individual insurance eligibility across their health organization. Unfortunately, in 2018, this problem persists, requiring medical service organizations to check insurance eligibility of providers one at a time.

Despite these challenges, Starkman emphasized that “CMS is working very hard to develop these tools and is making a lot of progress, even adding a new objective of QPP in 2018 to define and implement technology, making it easier for users to submit their data and get feedback.”

Determine your path to success

The Quality Payment Program has two tracks, MIPS and APMs, ** with most organizations reporting under MIPS, either through individual or physicians practice group reporting paths. Depending on size, resources and performance scores, Starkman said it may or may not be advantageous to submit MIPS scores in the MIPS track as a collective group at the TIN level, or as individuals at the NPI level. Another variable is how MIPS scores are submitted, either as Administrative Claims, EHR, Registry/QCDR and Attestation.

“The thresholds that you are measured against are going to be different if you submit through an EHR versus a registry, with some better for a registry and others for an EHR,” he explained.

Weighing the benefits of submitting as a medical practice group versus by individuals is also a key consideration. “Unless you have an exceptional case, most organizations will benefit most by going in as a group versus an individual. Going this route also avoids the risk of individual practitioner scores being posted online,” he explained.

Ensure all available points are captured

Another way to improve scores is to take advantage of bonus points. Two MIPS categories include bonus points, with high-value quality measures earning up to 10 percent. Submitting via an EHR or through end-to-end electronic reporting can also gain you up to 10 percent. Using a 2015 Edition CEHRT will score 10 MIPS ACI bonus points, while reporting data to additional registries will award 15 bonus points. The Improvement Activities category can earn 10 bonus points for ACI by completing at least one of the specified activities using a CEHRT, with the maximum number of bonus points allowed in the MIPS ACI category maxing out at 25.

“The bonus points are all about moving toward automation, including data-sharing and improvement activities, which CMS – and all of us – want,” Starkman said. “When you develop your strategy, you’ll want to look at how you can leverage the bonus points to your advantage.” He added that a registry can help health care organizations determine the bonus points they qualify for.

Program governance

If you are not familiar with CMS resources, or if you don’t have access to a user account where you can review your quality data and obtain Quality Resource Use Reports (QRURs), you could be missing out on important information, including checking the status of your MIPS data submission.

Starkman explained that lack of access is most typically due to an entity not having an Enterprise Identity Management (EDIM) username. This often occurs if the person responsible for quality reporting is no longer affiliated with the reporting entity.

“If you don’t have credentials to get onto the portal, go to and request an EDIM by adding your TIN as a value-based reporting entity,” he explained. “Your Quality Resource Use Report (QRUR) will tell you how your practice has scored in the areas of Cost and Quality, and that is something you’ll want to have access to.”

Moving from data to actionable information

“It goes without saying that if you don’t have actionable data you don’t have much,” Starkman emphasized, noting that true value only comes from reliable data that has been cleared of duplication, reviewed and corrected from errors and accurately mapped to support comprehensive hospital analytics to create meaningful revenue cycle dashboards.

“It is not just about product compliance,” he explained. “You want to know how you are doing in real life. It is important to audit your reports and make sure you trust what you are getting, identify gaps and work toward closing them. This is fundamentally important and moves us from ‘did you put those codes in?’ to ‘Where can we go from here? What strategic analysis can we draw from these codes?’” He added that good data can also help with aligning health care providers towards organizational goals.

Do not assume what the final MACRA rule will be

Starkman’s final lesson learned is never to assume what the final rule will be. “Don’t build your whole system hard coded to the proposed rules,” he emphasized, “because CMS is continuously receiving feedback and the measures could change. Be flexible and understand that you have to have time and resources allocated for end-of-year to react to what the final rule ends up being. There will inevitably be new challenges that you’ll need to address.”

Listen to the full MACRA Education webinar, “Quality Payment Program Year 1: Lessons Learned,” and visit the nThrive health care management webinar repository to explore a full library of MACRA webinars to help you on your QPP journey. Interested in engaging with a registry, go here for more information.

* Medicare Access and CHIP Reauthorization Act of 2015

** Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs)