Kentucky REC News


In our second episode of the PILL podcast focused on diabetes prevention and treatment, Trudi speaks with Dr. Tamea Evans, a 2003 graduate of the University of Kentucky College of Medicine. Dr Evans is an Internal Medicine physician and diabetologist who is passionate about helping patients with long term illness get the tools and knowledge they need in order to get and stay well. Listen as she shares what it means to be “blessed by bad” and how doctors can be rewarded for doing a good job.

This episode includes a focus on diabetes self-management education and support (DSMES), a fundamental but underutilized element of diabetes care. Kentucky has around 95 recognized or accredited DSMES programs and branches serving 88 counties across the Commonwealth. To find locations, click here and search for “Nationally Recognized or Accredited Diabetes Self-Management Education and Support Classes”.

Listen to our podcast on Buzzsprout, or Spotify and Apple Podcasts. All previous episodes are 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.


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.


Program Year 2019 is almost over for the KY Medicaid Promoting Interoperability Program. Be sure you have ALL of your documentation compiled and ready to submit. The Kentucky Medicaid EHR Incentive Program (Promoting Interoperability) is accepting program year 2019 attestations until 11:59 p.m. March 31, 2020. Any attestation not submitted will be closed out and ineligible for participation for the program year.



1. Individual Provider NPI and EHR Incentive Program Registration Tracking ID (assigned upon registration with CMS) used to log into website to submit attestation (Not required for upload, just need for log-in)
2. Public Health or Clinical Data Registries – Required uploads will vary based on providers’ level of engagement with KHIE or other public health or clinical data registries; see below:

  • Option 1: Completed Registration to Submit Data to KHIE: Participation Agreement and all signed addendums required (upload required), and registration documentation should be kept for audit purposes
  • Option 2: Testing and Validation to KHIE: Testing and Validation Confirmation (upload required) Other Registries: Documentation of completed testing should be kept for audit purposes
  • Option 3: Production to KHIE: Go-Live Approval Form (upload required) Other Registries: Confirmation of production data should be kept for audit purposes

3. Promoting Interoperability reports must be uploaded for the qualifying 90 day period for each individual EP attesting
4. Electronic Clinical Quality Measure (eCQM) report should be generated for the applicable reporting period as a QRDA-III file for each EP attesting. If a QRDA-III file is unavailable, eCQM report should be saved as a PDF for upload.
5. Payment Reassignment document: Documentation is required for all EPs that attest for incentive payments through the Kentucky Medicaid Promoting Interoperability Program. This is required for all providers that reassign payment to an entity other than themselves.
6. Documentation must be uploaded to the attestation in the form of a signed agreement indicating EP is permitting their monies to be reassigned. The agreement shall be on the entities clinic or group letterhead, renewed each payment year and to include all information below:

  • Name and NPI of EP participating in the incentive program
  • Program Year and Payment Year EP agrees to reassign incentive monies
  • Name, NPI & TIN of clinic or group payment will be reassigned to
  • Signed and dated by EP
  • Signed and dated by authorized representative of entity receiving incentive payment on behalf of the EP

7. Patient Volume Report for a 90 day period, during or prior to the calendar year of the reporting period for attestation. A patient volume report form is available here.
8. When requesting a KCHIP report, if applicable, allow adequate time for receipt before attesting as this report can take up to 3 hours to complete.
9. Signed vendor contract, invoice or purchase order (documentation must be a legally binding contract) with current software version number listed to support the 2015 version CEHRT ID. Any other documentation supporting Yes/No attestation responses, testing with other entities, etc.
10. EHR Certification ID for current version (2015) from the CHPL website.

Contact your Health IT Advisor at the Kentucky Regional Extension Center to assist you with reviewing your Stage 3 reports, or with any questions you may have regarding the attestation process or suggested documents to retain. Also, be certain to schedule a time with your Health IT Advisor to submit your attestation. Kentucky Medicaid provides a manual for Eligible Provider Meaningful Users here.

Contact us at Kentucky REC with your questions about the Promoting Interoperability Program. Our team of experts is 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.