Kentucky REC News


Performance Year 5, 2021, of the Quality Payment Program (QPP) is over halfway over! During our next QPP webinar, Kentucky REC experts will discuss the details of the Improvement Activities (IA) Performance Category to help you make informed decisions for improvement.

The Improvement Activities (IA) Performance Category aligns very well with processes we are already doing to improve our practices. The Final Rule changes for reporting in this category require more preparation and planning than previous years. We will discuss what you should keep in mind as we move toward finishing the 2021 Performance Year, ranging from best practices, to documenting as a large organization, and how to find the right activities for your organization.

QPP Year 5 Webinar: Improvement Activities Performance – Creating a Catalyst for Improvement*
Wednesday, September 22, 2021 @ 12PM ET

*This webinar is for Kentucky REC contracted QPP clients only. If you are interested in this topic and would like to learn more about becoming a client, please contact us at (859)323-3090 or email us at We aim to be your trusted healthcare advisor!


Review your 2020 QPP/MIPS Final Feedback Reports Today! Deadline for Review is October 1st.

MIPS clinicians should review both the Individual and Group final scores for the MIPS 2020 performance year, even if you have already reviewed the report.

Reviewing your final scores is very important because clinicians who were individually non-eligible, but were eligible for Group-level submission for 2020, are being automatically scored for any Group-level Medicare Part B claims submissions. This could result in a negative payment adjustment up to 9% for these clinicians.

If you only submitted individually for your eligible clinicians, please make sure to review your Group-level score as well, so you can determine if any of your non-eligible individual clinicians received a final score and payment adjustment.

For the 2020 performance year, CMS automatically calculated a score for the Quality performance category at both the individual and group level. Those exempt providers were automatically scored because there was a claims submission which is at the-group level and the individual level as well. Additionally, the automatic extreme and uncontrollable circumstances policy applies only at the individual level for individually *eligible* clinicians, and does not cover the group nor those who are exempt individually. Because these NPIs were exempt individually, and eligible at the group level, and claims data was received at the group level, per policy they are receiving the appropriate group score and group payment adjustment.

If any of your clinicians received a score based on a Quality category claims submission, in which no other performance category data was submitted and received a negative payment adjustment, then it is urgent you complete a Targeted Review and submit before the 8 PM ET, October 1, 2021 deadline. In order to review your your feedback or request a targeted review, sign in HERE.

Questions? Contact your advisor or the experts at Kentucky REC. We’re here to help: 859-323-3090.


Join UK HealthCare’s Barnstable Brown Diabetes Center, UK College of Agriculture, Food and Environment Cooperative Extension Service, and United Healthcare Community Plan as they present:


WEDNESDAY AUG 11 12:30 – 1 PM ET


Divya B Cantor, MD, MBA, FACOG – Interim Chief Medical Officer – Community & State Medicaid KY – United Healthcare

Tami Ross, RD, LD, MLDE, CDCES, FADCES – Diabetes Education Services and Prevention Program Coordinator – UK Healthcare – Barnstable Brown Diabetes Center

Theresa Renn, BSN, RN, CDCES, MLDE – Director – Kentucky Diabetes Prevention and Control Program – Kentucky Department of Health

Mary Luvisi – KY Diabetes Learning Collaborative Director = UK Healthcare – Kentucky Regional Extension Center

Webinar Information: Join from PC, Mac, Linux, or mobile device:

For other access methods and further information, download this flyer.

Questions? Contact us atKentucky REC or call us at 859-323-3090.


Now Available: 2020 MIPS Performance Feedback, Final Score, and 2022 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for performance year 2020 and associated MIPS payment adjustment information for payment year 2022.

You can view your MIPS performance feedback, final score, and payment adjustment on the Quality Payment Program website.

You can access your 2020 MIPS performance feedback, 2020 final score, and 2022 payment adjustment information by:
• Going to
• Logging in using your HCQIS Access Roles and Profile (HARP) system credentials; these are the same credentials that allowed you to submit your 2020 MIPS data

If you don’t have a HARP account, please refer to the Register for a HARP Account and Connect to an Organization documents in the QPP Access User Guide and start the process now.

For Shared Savings Program ACOs, please note that beginning August 5, 2021, you will be able to create a HARP account and manage your account in the ACO Management System (ACO-MS). Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at or 1-888-734-6433 (Option 1).

To learn more about the information in your performance feedback, review the following 2020 MIPS Performance Feedback Resources:
NEW! 2020 Performance Period Benchmarks (ZIP) – Identifies the performance period benchmark results (as available) for measures without a historical benchmark and provides general information about performance period benchmarks.
2020 MIPS Performance Feedback FAQs (PDF) – Highlights what performance feedback is, who receives the feedback, and how to access it on the Quality Payment Program website.
2022 MIPS Payment Year Payment Adjustment User Guide (PDF) – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.

MIPS Eligible Clinicians Participating in MIPS Alternative Payment Model (APM) Entities

Individual clinicians and representatives of APM Entities will also be able to access performance feedback directly on the Quality Payment Program website using their HARP account. Note: Performance feedback is not related to model-specific requirements and assessments outside of the Quality Payment Program.

COVID-19 Flexibilities

CMS has continued to implement flexibilities for the Quality Payment Program in response to the COVID-19 pandemic. We applied the MIPS automatic extreme and uncontrollable circumstances policy to all individual MIPS eligible clinicians for the 2020 performance period, and we reopened the 2020 Extreme and Uncontrollable Circumstances Exception Application to allow requests for reweighting of the MIPS performance categories to 0% for groups, virtual groups and APM Entities.

The 2020 MIPS final scores available on the Quality Payment Program website reflect these COVID-19 flexibilities. Learn more about the COVID-19 flexibilities in the COVID-19 Response Fact Sheet and COVID-19 Response Webpage.


Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.
• Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

Now Available: 2020 MIPS Targeted Review

If you participated in the Merit-based Incentive Payment System (MIPS) in 2020, you can now review your performance feedback, including your MIPS final score and payment adjustment factor(s), on the Quality Payment Program website.

For MIPS eligible clinicians, your 2020 final score determines the payment adjustment you’ll receive in 2022, with a positive, negative, or neutral payment adjustment being applied to the Medicare paid amount for covered professional services furnished in 2022.

MIPS eligible clinicians, groups, and virtual groups (along with their designated support staff or authorized third party intermediary), including APM participants, may request that CMS review the calculation of their MIPS payment adjustment factor(s) through a process called targeted review.

When to Request a Targeted Review

If you believe an error has been made in the calculation of your MIPS payment adjustment factor(s), you can request a targeted review until October 1, 2021. Some examples of previous targeted review circumstances include the following:
• Data was submitted under the wrong Taxpayer Identification Number (TIN) or National Provider Identifier (NPI)
• Eligibility and special status issues (e.g., you fall below the low-volume threshold and shouldn’t receive a payment adjustment)
• Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances

Note: This is not a comprehensive list of circumstances. If you have questions about whether a targeted review is warranted for your circumstance, please contact the Quality Payment Program.

How to Request a Targeted Review

You can access your MIPS final score and performance feedback and request a targeted review by:
• Going to the Quality Payment Program website
• Logging in using your HCQIS Access Roles and Profile System (HARP) credentials; these are the same credentials that allowed you to submit your MIPS data. Please refer to the QPP Access Guide for additional details.

For Shared Savings Program ACOs, please note that beginning August 5, 2021, you will be able to create a HARP account and manage your account in the ACO Management System (ACO-MS). Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at or 1-888-734-6433 (Option 1).

CMS generally requires documentation to support a targeted review request, which varies by circumstance. You’ll be contacted by a representative with information about any specific documentation required. If the targeted review request is approved and results in a scoring change, we’ll update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Please note that targeted review decisions are final and not eligible for further review.

For more information about how to request a targeted review, please refer to the 2020 Targeted Review User Guide (PDF). For more information on payment adjustments please refer to the 2022 MIPS Payment Year Payment Adjustment User Guide (PDF).


Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

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


On April 27, 2021, the Centers for Medicare & Medicaid Services (CMS) issued the proposed rule for fiscal year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH). Please see additional details below.

CMS has specifically proposed the following changes to the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals:

  • Continue the EHR reporting period of a minimum of any continuous 90-day period for new and returning eligible hospitals and CAHs for CY 2023 and to increase the EHR reporting period to a minimum of any continuous 180-day period for new and returning eligible hospitals and CAHs for CY 2024;
  • Maintain the Electronic Prescribing Objective’s Query of PDMP measure as optional while increasing its available bonus from 5 points to 10 points;
  • Modify technical specifications of the Provide Patients Electronic Access to Their Health Information measure to include establishing a data availability requirement;
  • Add a new Health Information Exchange (HIE) Bi-Directional Exchange measure as a yes/no attestation, beginning in CY 2022 to the HIE objective as an optional alternative to the two existing measures;
  • Require reporting “yes” on four of the existing Public Health and Clinical Data Exchange Objective measures (Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, and Electronic Reportable Laboratory Result Reporting) or requesting applicable exclusion(s);
  • Attest to having completed an annual assessment of all nine guides in the SAFER Guides measure, under the Protect Patient Health Information objective;
  • Remove attestation statements 2 and 3 from the Promoting Interoperability Program’s prevention of information blocking attestation requirement;
  • Increase the minimum required score for the objectives and measures from 50 points to 60 points (out of 100 points) to be considered a meaningful EHR user; and
  • Adopt two new eCQMs to the Medicare Promoting Interoperability Program’s eCQM measure set beginning with the reporting period in CY 2023, in addition to removing four eCQMs from the measure set beginning with the reporting period in CY 2024 (in alignment with proposals for the Hospital IQR Program).


Questions? Contact the experts at Kentucky REC for all your hospital Promoting Interoperability questions. We’re here to help: 859-323-3090.


The Kentucky Medicaid EHR Incentive Program for Eligible Providers (EPs) ends August 31st, 2021

This CMS program, formerly named Medicaid Meaningful Use, has been in effect for 10 years. Over the life of the program, it has offered many providers across the Commonwealth an opportunity to submit information from the use of their electronic medical record for annual incentive payments. If you have providers who have attested to the Medicaid program in the past, or maybe you aren’t sure and would like to check their eligibility, please contact us at the Kentucky REC. We will assist you in determining eligibility, and provide grant-funded assistance from experienced advisors in meeting the requirements for participation.

The reporting period for 2021 is a 90-day performance period and that last 90-day opportunity began on June 2nd. However, you can report any consecutive 90-day period in 2021 that meets the performance requirements. Providers must provide a volume report that indicates at least 30% of their patient volume includes Kentucky Medicaid as an insurer. Pediatricians can report if they have 20% of their patient volume that includes Kentucky Medicaid. Our experienced advisors can help you with calculating this information, assist with attestation, and review documents for audit support, through grant-funded free assistance. Therefore there is no cost to providers for these services.

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


Join our partners at KHIE (Kentucky Health Information Exchange) for the 2021 virtual eHealth Summit, as they share the transformation of Health Information Technology (HIT) and KHIE technological enhancements over the past year. As the pandemic exposed new challenges in HIT, KHIE responded by implementing new features and services such as Patient Alert Query Service, Direct Data Entry for labs providing COVID-19 test results, Electronic Case Reporting for reportable diseases, the new Image Exchange, and much more.

Click here to see a full menu of KHIE services.

Highlights of the Day

Dr. Alecia FarleeseKeynote Speaker – 9 am: Dr. Alicia Farlese will provide insight on the state of HIT from a national perspective, with particular emphasis on federal HIT policy changes, and their impact on Kentucky healthcare providers. Dr. Farlese, DNP, RN-BC, is a retired Captain/O-6 and previous senior leader in national health IT policy and programs at the US Department of Health and Human Services, contributing to many health IT regulations, such as the 21st Century Cures Act.

Healthcare Panel 10 am: Commentary on the Role of Health IT Post-Pandemic: Chief Medical Officers (CMOs) across Kentucky will provide insight on the status of Health Information Technology from a state perspective, with particular emphasis on the impact of COVID-19 on Kentucky healthcare providers.

KHIE Service Spotlight 11 am: Social Determinants of Health: KHIE representatives will share how they are partnering with kynect resources, the Commonwealth’s web-based community resource portal, to link Kentuckians to appropriate resources to help mitigate the impact of social determinants of health (SDoH) on vulnerable populations in Kentucky.

Afternoon Breakout Sessions

Analytics: As a result of the evolving COVID-19 reporting requirements, KHIE implemented Direct Lab Data Entry and Electronic Case Reporting to efficiently align with Public Health reporting obligations. KHIE facilitated mandatory COVID-19 test lab reporting through Direct Lab Data Entry and automated the generation and transmission of case reports for reportable conditions through the implementation of Electronic Case Reporting. Learn more about KHIE’s public health efforts during the Analytics Breakout Sessions.

Image Exchange: KHIE’s Image Exchange Service affords healthcare providers the ability to share clinical images, view images in KHIE’s ePartnerViewer, and export images to a destination Picture Archiving and Communication System (PACS) for viewing in high-resolution. The aim of this service is to provide easy access to diagnostic studies and images. Learn more about KHIE’s Image Exchange and the Image Exchange Pilot Program during the KHIE Services Breakout Sessions.

Telehealth: Donna Veno, Director of the Division of Telehealth Services, will present on Kentucky’s actions to enhance telehealth utilization during the COVID-19 pandemic and how best to regulate telehealth post-pandemic. Areas of discussion include: federal temporary relaxed restrictions; Kentucky actions including new statutes, emergency orders and regulatory guidance related to Medicaid and Health Benefit Plans during the pandemic; and what legislative and regulatory changes are necessary for permanent changes post-pandemic.

HIPAA: It’s not easy to remember all the requirements that come with the HIPAA Security Rule. In this presentation, we will provide a checklist and guidance on various HIPAA security tools and resources that you need readily accessible when it comes to making sure your organization stays compliant. We’ll also take a look at the HIPAA regulatory updates introduced for 2021.

Quality Improvement: Major changes are happening to quality initiatives in 2021, 2022, and beyond, as we watch certain long term programs sunset, and others become more demanding. At the same time, new and upcoming initiatives join to make quality and the expectations on healthcare providers even more complex in the near future. What will the next few years look like? How do you keep up with everything to maximize performance?

2021 eHealth Summit Agenda

Questions? Contact the KHIE Planning Committee at



The 2022 Program update for the Quality Payment Program has been released in the latest Physician Fee Schedule Notice for Proposed Rulemaking (NPRM). Our experts at the Kentucky REC will host a webinar on all of the updates to the Quality Payment Program MIPS track, and the Alternative Payment Model pathway.

CMS is moving from a siloed approach with individual categories, to a more aligned program using pathways for Alternative Payment Models (APMs). As expected, CMS is also providing more guidance in the MIPS Pathway model. Going forward, the MIPS pathway will include population health measures, promoting interoperability, and other measures that impact chronic health conditions.

During our webinar we will share:

  • proposed updates to the MIPS Pathway model
  • proposed updates to Alternative Payment Models (APMs)
  • the ending of the transition years of the program
  • alterations in quality measures that can be reported
  • changes in who is considered an eligible clinician

WEDNESDAY AUGUST 18 12:00 – 1:00 PM ET

Below find links to the Proposed Rule, the fact sheet, and resources for additional information. The comment period for the NPRM closes September 13, 2021.

2022 Physician Fee Schedule Proposed Rule

2022 Quality Payment Program Proposed Rule Overview Fact Sheet

Proposed Rule Resources

From CMS: Submit a Formal Comment by September 13

You must officially submit your comments in one of the following ways:
• Electronically, through
• Regular mail
• Express or overnight mail
• Hand or courier

Electronic comments are due no later than 11:59 p.m. ET on September 13, 2021 and mailed comments must be received by 5:00 p.m. ET, September 13, 2021.

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


Interested in improving care outcomes for Pediatric Patients with Asthma?

The Kentucky REC, as a trusted partner with the Kentucky Department for Public Health, is participating in an exciting grant opportunity funded through the Centers for Disease Control (CDC). The goals are to improve the reach, quality, effectiveness, and sustainability of asthma control services, and to reduce asthma morbidity, mortality, and disparities throughout the state of Kentucky using the CDC’s EXHALE module.

This unique opportunity focuses on improving asthma care and education for pediatric patients, partnering with and improving school-based & community-based access to resources, and stream-lining referral processes for continuity of care in pediatric patient populations with asthma. The program lasts from June 1, 2021 – June 30, 2022.

The program includes:
• Advisory support for Quality Improvement
• Access to Asthma Self-Management Education and Support resources
• Practice tools
• Training opportunities for participating clinicians and staff
• Financial support: $2,500 for participation July 2021 – June 2022
• Deadline to Apply: July 31st, 2021

Contact us at Kentucky REC or call 859-323-3090 to learn more about how you can participate.



DATE CHANGE! This webinar was originally scheduled July 28. However, as of July 27, CMS has not released the 2020 Feedback Reports. Therefore we are re-scheduling for September 1st.

Your QPP Feedback Report for the 2020 Program Year contains a lot of information to help you identify areas for improvement. Our Kentucky REC expert advisors will guide you through the Feedback Report and explain how you can use the information to help you finish 2021 well, and push you into a strong start for 2022!

We will discuss how to unpack the information from CMS to understand your payment adjustment, and identify both opportunities and strengths across the four performance categories. We’ll also share how you can leverage that information to help you plan for the future.


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