Kentucky REC News


The QPP Resource Center for CMS designated small practices (fewer than 15 clinicians) now offers a Qualified Registry to users of the Resource Center Portal. Eligible clinicians can use MIPScast® Qualified Registry to submit their data to CMS.

Read through the 2019 Participation Guide for an overview, explanation, and reasons to consider using MIPScast® as a Qualified Registry for reporting to CMS. It also includes registration steps, how to access the necessary consent forms through the portal, and important dates to keep in mind.

Reasons to Consider Using MIPScast® QR for Reporting to CMS:
You may want to use the MIPScast® QR reporting option simply for the convenience of having a trusted partner do the submission work for you, and skip HARP account access requests and connecting to providers to submit data. Perhaps you want the confidence of knowing your data has been reviewed to check for completeness, catch potential validation issues earlier, and that it includes any available reporting options/bonuses that can boost your total score.

Many clinicians are still without the functionality and updated reports from their EHR technology to get the performance data they need for eCQMs and Promoting Interoperability measures. Some will need an alternative to reporting eCQMs from the EHR due to vendor issues including:

  • Vendor having difficulty attaining 2015 certification or using de-certified EHR technology
  • Unable to upgrade and implement 2015 technology in a timely manner due to vendor issues or delays
  • Reporting/data issues (e.g. limited eCQM availability, invalid QRDA 3 reports, inability to produce group-level aggregated reports)
  • Having to acquire and implement additional 3rd party technology to support your functional needs and reporting requirements
  • Cost barriers (e.g. additional costs for eCQM report access, eCQM access bundled with costly data submission services)
  • Difficult eCQM workflows, system configuration, and clinical documentation requirements leading to low performance results

Claims-based reporting for the Quality Performance Category is one alternative, but you have to submit Quality Data Codes (aka “G-codes”) on your Medicare claims throughout the 12-month performance period to get credit. Another alternative is to report through a QR such as MIPScast® , which provides the option to report MIPS CQMs (formerly referred to as “Registry measures”) which can only be collected and submitted by QRs and QCDRs.

Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.



The start of a new year brings many additions to your to-do list. Between wrapping up the 2019 program year and preparing to attest, and beginning the 2020 performance period with all of its changes, it can seem like too much to keep up with.

To help kick off the year, and a new decade, our first webinar will help you sort and manage your QPP to-do list for 2020. This will help ensure you are making progress toward meeting goals and not letting anything slip between the cracks.

We will guide you through:

  • creating an Action Plan for the 2020 Program Year
  • key areas to concentrate on in 2020
  • preparing for the 2019 QPP attestation
  • identifying areas of focus for Quality
  • month by month break down

Join us as we discuss the four performance categories and how to create a plan to set you and your practice up for success!

QPP Year 4: Planning for Success

Thursday, January 16, 2020 12:30 PM ET


Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.


With the calendar year drawing to a close, it’s time to develop your plans for submission to Year 3 of the Quality Payment Program. A great deal of hard work goes into a successful QPP submission. Much of your information gathering and documentation can actually be done now, or at least lined up for quick collection at the close of 2019.

Both Improvement Activities and Promoting Interoperability performance categories allow some flexibility in data reporting timeframes. You can select 90-continuous days for reporting for either category throughout the calendar year. This flexibility allows you to work ahead of the submission deadlines by gathering reports or other required documentation for the associated measures.

While Quality and Cost have a full year reporting requirement, you can implement strategies now for a strong finish to the 2019 performance year. Keep in mind that Cost is based upon Medicare Part B claims submitted to CMS during the performance year, so there is no additional information that to be submitted for attestation.

We’ll discuss how to put your practice in the best position for submission success. Don’t miss this opportunity to engage with your experts at Kentucky REC and have your QPP questions answered by our team of Quality Improvement Advisors!

QPP Year 3: Attestation Prep

Thursday, December 5, 2019 12:30 PM ET


Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.


On November 1st CMS released the highly anticipated Quality Payment Program Year 4 Final Rule. This Final Rule will impact and shape the Quality Payment Program for Program Year 4, calendar year 2020, and beyond.

We would like to answer your specific questions during the webinar. Therefore, please submit any questions or contact us in advance here.


QPP Year 4 Webinar: Final Rule 2020
Tuesday Nov 26 12:30 – 1:30 PM ET


Download the 2020 PFS/MACRA/Quality Payment Program Final Rule from the Federal Register here.
Read the Year 4 Final Rule Overview Fact Sheet and Executive Summary produced by CMS here.

Contact the experts at Kentucky REC for all your QPP, MIPS, and APM questions. We’re here to help: 859-323-3090.


The Centers for Medicare & Medicaid Services selected Altarum Institute and the Trustees of Indiana University as Prime awardees of the Network of Quality Improvement and Innovation Contractor. The Kentucky Regional Extension Center, an outreach arm of UK HealthCare, is a sub-awardee for both of these Prime awardees.

This designation will allow NQIICs to bid on Task Orders over the next five years.

Under the new CMS Indefinite Delivery/Indefinite Quantity (IDIQ) contract mechanism to support quality improvement efforts, each NQIIC may serve as:

• Quality Improvement Experts
• Facilitators/change agents for healthcare transformation by achieving bold aims at a high value
• Innovators of quality improvement

As a NQIIC awardee, UK HealthCare’s Kentucky Regional Extension Center has demonstrated healthcare quality improvement expertise.
Services supported by some of the NQIIC awardees may include:

• Provide direct technical assistance in specific areas of healthcare quality improvement (e.g., patient safety, opioid misuse, nursing home quality, etc.)
• Seek and gain commitments from patients, providers and stakeholders to achieve aims
• Use a Human Centered Design that involves teaming with patient and family members to improve healthcare processes and outcomes
• Focus on helping providers and healthcare organizations to achieve quantitative results for improved outcomes, lower costs, better care, less provider burden, greater transparency, and more
• Support a diverse array of organizations and populations, including: rural providers, vulnerable beneficiaries, clinical practices, hospitals, nursing homes, dialysis facilities, and more
• Support providers in efficient use of Health Information Technology and interoperability
• Serve as backbone organizations to form and engage Community Coalitions
• Convene and support Learning and Action Networks (LANs)




CMS has posted 6 continuing medical education (CME) modules on the Merit-based Incentive Payment System (MIPS). You can access them by logging into your Medicare Learning Network (MLN) account or creating one here. Once logged in, type the name of the module into the search bar at the top of the website to find it.

The new MIPS CME modules include:

• Quality Payment Program 2019 Overview – Provides information on the origin and objectives of the program as well as an overview of the MIPS and Advanced Alternative Payment Models.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Participation in 2019 – Details MIPS eligibility and participation options, including the new opt-in policy, and how to report MIPS data.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Quality Performance Category in 2019 – Explains the requirements, data submission and collection types, and scoring for the Quality performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Promoting Interoperability Performance Category in 2019 – Provides information on reporting requirements, measures, and reweighting for the Promoting Interoperability performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Improvement Activities in 2019 – Explains the requirements, reporting steps, and scoring for the Improvement Activities performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Cost Performance Category in 2019 – Provides information on new measures, attribution, and scoring for the Cost performance category.

For More Information
• Visit the MLN Web-Based Training webpage and log in to MLN to access the modules.
• Visit the QPP Resource Library to review new and existing QPP resources.
• Contact the Quality Payment Program at or 1-866-288-8292 (TTY: 1-877-715-6222). To receive assistance more quickly, consider calling during non-peak hours—before 10 AM and after 2 PM ET.

Contact us at Kentucky REC with your questions about the Quality Payment Program. Our team of experts is here to help: 859-323-3090.




Announcing Episode 5 – Hank Kerschen – Accountable Care Organizations

In this episode of The PILL podcast, Trudi interviews Hank Kerschen, a healthcare executive experienced in multi-specialty group practices and integrated delivery systems. He excels in group development, strategic planning, relationship management, and project management. He discusses the process and benefits of joining an Accountable Care Organization (ACO), and the journey of St. Elizabeth to participate in a value-based care model. He also addresses how to navigate being in both of the healthcare reimbursement worlds of fee-for-service and value-based care at the same time.

You can now listen to our podcast at our new home, Buzzsprout, or listen on Spotify or Apple Podcasts. All previous episodes are now available.

If you need assistance with quality improvement and/or the QPP, contact the Kentucky REC at 859-323-3090 or by email. For specific Quality Payment Program assistance for small practices, visit the online resource center.


How can a Security Risk Analysis from the Kentucky REC help?

Our highly trained staff can help your organization reduce your breach and ransomware risk through a Risk Analysis. By performing interviews, facility walkthroughs and looking at your documentation, then matching your existing controls to industry best practice, you will receive a thorough view of your vulnerabilities. Once the vulnerabilities are identified, they will be outlined in a final report, with recommendations where compensating controls to reduce ransomware risks are needed. Details on the Breach Notification Rule can be found here.

 Additional Resources

HHS Breach Notification Rule

HHS Submitting Notice of Breach

Contact the security experts at Kentucky REC with your HIPAA and security questions. Email at or call us at 859-323-3090.



From CMS…

Thursday, October 3rd is the Start of the Last 90-Day EHR Reporting Period for the Promoting Interoperability Programs

The Centers for Medicare & Medicaid Services (CMS) would like to remind Medicare Promoting Interoperability Program participants that the electronic health record (EHR) reporting period in 2019 is a minimum of any continuous 90-day period in CY 2019, through December 31, 2019.

Thursday, October 3rd is the last possible start date for the 90-day EHR reporting period for new and returning eligible hospitals, dual-eligible hospitals, and critical access hospitals (CAHs) in 2019. Failure to demonstrate that a hospital or CAH is a meaningful EHR user for a continuous 90-days will result in a downward payment adjustment.

In addition to a continuous 90-day EHR reporting period and other program requirements, Medicare Promoting Interoperability Program participants must:
• Use 2015 Edition Certified EHR Technology (CEHRT) for a minimum of any continuous 90-day period
Note: The 2015 Edition CEHRT did not have to be implemented on January 1, 2019, but the functionality must be in place by the first day of the EHR reporting period.
• Submit a “yes” to the Prevention of Information Blocking Attestations
• Submit a “yes” to the ONC Direct Review Attestation
• Report the required numerator and denominator or yes/no measures from each of the four objectives or claim their exclusion(s)
• Earn a minimum total score of 50 points
• Report on four self-selected eCQMs from the set of 16 available

For More Information
To learn more about these requirements, please review the:
2019 Medicare Promoting Interoperability Program Requirements
FY 2019 IPPS and Medicare Promoting Interoperability Program Overview Fact Sheet

For more information on the Promoting Interoperability Programs, visit the Promoting Interoperability Programs website.

Contact us at Kentucky REC with your questions about the Promoting Interoperability Program. Our team of experts is here to help: 859-323-3090.


The quality team at Kentucky REC is excited to host a collaborative webinar with two guest experts: Bruce Maki, a Regulatory Analyst and Program Manager for QPP Advisors at Altarum in Michigan; and Samuel Ross, a Health Informatics Facilitator from Chicago Health IT Regional Extension Center. Bruce and Samuel bring knowledge and skill in healthcare policy and the Quality Payment Program.

Together we will answer your questions and concerns about the QPP. Whether you are in a large or small practice, this session will help you better understand your flexibilities within the program and grasp how to shoot for that potential positive incentive.

Webinar – QPP Year 3: Experts Answer Your QPP Questions
Tuesday October 22, 12:30 – 1:30 p.m. ET

Contact us at Kentucky REC with your questions about the Quality Payment Program. Our team of experts is here to help: 859-323-3090.