Kentucky REC News

Join us for a MACRA 2016 Feedback Report Webinar on Monday, October 30th

On September 18, 2017, CMS released the annual Quality and Resource Use Reports (QRUR) for all group and solo practitioners across the country. We hope that you can join us for a live webinar where we will be digging into the 2016 QRUR. During this webinar we will be highlighting some key aspects of the report as well as how you can use this report to drive improvement in your practice.

In addition, we will be discussing the supplemental tables and how these tables can be used to focus in on target populations to improve outcomes and reduce overall cost. We highly encourage that you pull your 2016 QRURs so that you can follow along as we walk through a sample QRUR and discuss each section and how this feedback report can be used to improve your MIPS performance in the future.

What: MACRA 2016 Feedback Report Webinar
When: Monday, October 30, 2017 12:00 pm


Quality Payment Program Hardship Exception

The Quality Payment Program Hardship Exception application for the 2017 transition year is now available on the Quality Payment Program website.

MIPS eligible clinicians and groups may qualify for a re-weighting of their Advancing Care Information (ACI) performance category score to 0% of the final score, and can submit a hardship exception application for one of the following specified reasons:

-Insufficient internet connectivity
-Extreme and uncontrollable circumstances
-Lack of control over the availability of Certified EHR Technology (CEHRT)

There are some MIPS eligible clinicians who are considered Special Status, who will be automatically re-weighted (or, exempted in the case of MIPS eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.  In addition to submitting an application via the Quality Payment Program website, clinicians may also contact the Quality Payment Program Service Center and work with a representative to verbally submit an application.

To submit an application, you will need:
-Your Taxpayer Identification Number (TIN) for group applications or National Provider Identifier (NPI) for individual applications
-Contact information for the person working on behalf of the individual clinician or group, including first and last name, e-mail address, and telephone number
-Selection of hardship exception category (listed above) and supplemental information.

If you’re applying for a hardship exception based on the Extreme and Uncontrollable Circumstance category, you must select one of the following and provide a start and end date of when the circumstance occurred:
-Disaster (e.g., a natural disaster in which the CEHRT was damaged or destroyed)
-Practice or hospital closure
-Severe financial distress (bankruptcy or debt restructuring)
-EHR certification/vendor issues (CEHRT issues)

For More Information, please contact the Quality Payment Service Center at 1-866-288-8292 or TTY: 1-877-715-6222 or or visit

Contact Kentucky REC at 859-323-3090. Our experts are here to help.

Upcoming Web Event: Maximizing MIPS ACI Scores for Small Group Practices and Solo Clinicians

Obtaining a high Advancing Care Information (ACI) score is essential for small group practices seeking to achieve bonuses in the MIPS program. But, because many small practices have limited or no electronic health records and may not participate in registries, achieving a good ACI score may seem difficult.

This event will help small practices understand ACI scoring and advise them on how to maximize their limited resources to earn the best ACI score possible. Panelists will discuss the ACI measures required for reporting, how to choose quality measures, ACI measures, and improvement activities that can maximize your efficiency, eligibility for a hardship exemption, and what to do if your practice does not have an EHR or use a registry.

This event is designed for:

  • MIPS-eligible clinicians from solo and small practices with 15 or fewer clinicians
  • Practice managers and other staff tasked with submitting MIPS data
  • Clinician stakeholders such as State and Medical Associations assisting small practices preparing to participate in MIPS

Two sessions of this presentation are being offered. Please click the date and time to register for the session you would like to attend:



See the flyer to learn more. This event is being hosted by the QPP SURS Central Support Team, you may contact them at:

Hospital Meaningful Use Update from CMS

Eligible Hospitals and Critical Access Hospitals: Submit Meaningful Use Data to the Hospital Quality Reporting System (HQR) via the QualityNet Secure Portal in 2018

CMS has issued the following guidance regarding the notice “Submit Meaningful Use Data to the Hospital Quality Reporting System (HQR) via the QualityNet Secure Portal in 2018” issued on August 7, 2017.

The Medicare EHR Incentive Program Registration and Attestation System will NOT be available for hospitals after December 31, 2017. Hospitals attesting to the Medicare EHR Incentive Program will register and attest in the HQR system. However, the Quality Net Secure Portal is not yet setup to accept attestations for CY 2017. Hospitals will attest to their 90 day reporting period for 2017 starting on January 2, 2018 through February 28, 2018. More information, including a user guide will be made available by CMS closer to January. All hospitals will need to update their log-in information to include Meaningful Use (MU) in Quality Net. This will be available in October and additional details will be released closer to the date.

The following CMS FAQs may be helpful:

Q: Some hospitals already have a Quality Net account as they have submitted electronic Clinical Quality Measures in the past. Will they need to create a separate log-in for HQR to attest to MU or will their previous log-in suffice for MU attestation too?
A: It is our understanding that registration to the site will only occur one time and that hospitals will be able to utilize their already established login information. However, for official confirmation, we recommend that hospitals submit this question by logging into the QualityNet Secure Portal and clicking submit this question to the QualityNet support team via the portal, contacting the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222), or emailing the QualityNet help desk at

Q: Will hospitals that have never submitted eCQMs to Quality Net previously need to create a new account in order to attest to MU?
A: Yes, correct.

Q: How long do you anticipate the registration process will take and are there instructions on how hospitals will do so?
A: All users requesting access to the QualityNet Secure Portal must be individually approved and verified. This mandatory registration process is used to maintain the confidentiality and security of healthcare information and data transmitted via QualityNet. Providers can register here and must select the appropriate user classification. The QualityNet Security Administrator facilitates the registration process for other users at the organization. Typically, an organization designates two Security Administrators. Providers submitting data via the QualityNet Secure Portal (or using a vendor to submit data on their behalf) are required to designate a Security Administrator. All other registered QualityNet users in an organization are considered basic users. The QualityNet website lists instructions regarding registration, sign-in instructions, password rules, etc. on the left side of the screen.

Q: For 2017, will hospitals continue to be able to submit Clinical Quality Measures via aggregate reporting as they did within the CMS Registration and Attestation System in the new HQR system?
A: The data receiving system is accepting submissions of QRDA Category I (patient level files) test and production files for the Hospital IQR and the Medicare EHR Incentive programs CY 2017/Fiscal Year (FY) 2019 electronic reporting requirements. The system was updated to accept QRDA Category I test and production files utilizing the CY 2017 requirements.

Technical Specifications for CY 2017 Reporting

Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) that seek to report eCQMs under the Hospital IQR and the Medicare EHR Incentive programs must use the following:

Since the Registration and Attestation System will no longer be available after December 31, 2017 we encourage you to print out documentation from previous participation years to maintain for your records.

MIPS 2017: Time is Running Out

October 2nd has just passed, bringing the beginning of the last 90-day MIPS performance period for 2017. If plans aren’t already in place, this is the last opportunity you have to decide what to do if you are an Eligible Clinician (EC) impacted by MIPS. If there is any doubt about your participation status go here and enter your NPI number. That will let you know immediately if you need to do something in 2017 to protect your 2019 Medicare Part B reimbursement and professional reputation.

The MIPS Composite score is extremely important. There are four participation options for 2017 and at least one of them should be disregarded immediately. Option 1, doing nothing, will give you an automatic 4% Medicare Part B penalty in 2019 and a public MIPS score of 0. Option 2, test reporting, will avoid penalties in 2019 but leaves you with a MIPS score of 3. Option 4 requires submission of an entire year of data to Medicare. Probably not too many can pull that one off. That only leaves Option 3 as the only acceptable path for MIPS in 2017 for most ECs.

Option 3: CMS calls this “Partial Participation” and lays out the requirements: “If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and may even earn the max adjustment.” In addition, with the right strategy (individual vs. group reporting, submission method, choice of “MIPS friendly” vs. clinical quality measures, etc.) a high MIPS score can bring numerous advantages: positive scoring on public sites when rolled out, higher reimbursements, and more.

As we have entered the beginning of the last 90-day reporting period decisions and strategies will need to be in place to assure a high MIPS score. There will not be an opportunity to back pedal or second guess. Don’t let indecision or lack of knowledge of the MACRA/MIPS program adversely affect your Medicare Part B reimbursement, practice value, and professional reputation.

Our goal is not only to avoid penalties, but deliver actionable strategic decisions that lead to the highest possible MIPS score.

Contact the Kentucky REC now for help: 859-323-3090

Source: by Jim Tate