Kentucky REC News


It’s easy to forget how important the Improvement Activities (IA) performance category is to our success in the Quality Payment Program. It may sometimes feel like “busy work”, but if planned and executed appropriately, many of these activities align very well with processes we are already doing to improve our practices.

CMS has listed over 100 activities in the IA category. We will discuss how the category is scored depending on your status as a practice, and go through some example activities so you can see how IA works. Our experts will be available to answer your questions, and help you see efficiencies and overlaps with the other MIPS categories, and other programs such as PCMH/PCSP and Promoting Interoperability.


Webinar – QPP Year 3: Improvement Activities
Thursday April 4, 12:30 – 1:30 p.m. ET


Webinar March 21st – Year 3 QPP Expert Panel

Join us for our highly requested, first ever expert panel webinar in which we will answer your questions on Year 3 of QPP. All questions are valid: from those new to the Quality Payment Program, to those who have submitted since the beginning.

Send in your questions ahead of time to be included. Call us at 859-323-3090 or email Kentucky REC.

  • Brief overview of MIPS Year 3
  • Reimbursement
  • Thresholds
  • Timelines
  • Monitoring your progress

The panel will also discuss how the activities and improvements from MIPS can impact:

  • Your practice’s efficiency
  • Patient outcomes
  • Finances
  • Reputation
Don’t forget! Contact us with your questions now!

Webinar – QPP Year 3: Expert Panel
Thursday March 21, 12:30 – 1:30 p.m. ET



Dr. Roberto Cardarelli, Chief of the Division of Population Medicine and Chair of the Department of Family and Community Medicine at UK HealthCare is a Quality Improvement Guru. He is an expert in Population Health, which Wikipedia defines as: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group. It is an approach to health that aims to improve the health of an entire human population.”

In our interview, he explains why population health management is so important, especially for states like Kentucky, which struggles with poor health outcomes. Dr. Cardarelli takes population health management, a seemingly huge task, and breaks it into small, bite-size pieces: access and analyze your data; start with small tests of change; look at TCM (Transitional Care Management) and CCM (Chronic Care Management) to increase reimbursements; and lastly, be creative.


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 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.

Webinar March 7 – QPP Year 3: Cost Category

The Cost Category of the QPP is often cited as the most complex and difficult to grasp of the four categories. In Year 3 of the Qualify Payment Program, CMS made several changes to the cost category, and it is set to make up 15% of an Eligible Clinician’s or an Eligible Group’s MIPS final score. It will increase in weight for the MIPS program over time. Cost is calculated from Medicare Claims data during the performance year. The difficulty of analyzing actual attributions of Cost makes this category very challenging. It is essential to understand the influence of Cost on your final MIPS score.

We’ll go over the category in depth, highlighting the new changes and how they might affect you and your practice. Our goal is to alleviate some of the uncertainty and concern around this category. We’ll outline what you can do to positively impact your performance in the Quality Payment Program for 2019.

Webinar – QPP Year 3: Cost Category
Thursday March 7, 12:30 – 1:30 p.m. ET



Navigating the many systems to submit your QPP Year 2 data is challenging, even on the best day. With all the changes to the QPP submission system, updates, and new processes, it can be downright confusing. This article is to give you some guidance for your quality submission. However, due to the complexity of the program, there may be exceptions to this information. If you find yourself in a bind, call us at 859-323-3090 and one of our experts will be happy to answer your questions.

Keep in mind the four categories in play for the 2018 program year: Quality, Cost, Improvement Activities and Promoting Interoperability. At most, you will need to submit on three categories for 2018 (since Cost is calculated by CMS). Promoting Interoperability and Improvement Activities allow ECs or groups to submit by attestation or by having a 3rd party submit. The Quality performance category has more limits surrounding submission.

Submitting Your Quality Data

Either you or your EHR will need the capability to generate a Quality Reporting Document Architecture or QRDA III file. Contact your EHR vendor or registry, if applicable, to access this file if you are unable to generate it in your system. While a QRDA III file is required for Quality, it may also be used to submit data for Promoting Interoperability and Improvement Activities.

Typically there are two main ways to submit this QRDA III file:

1. Directly via the API – this workflow involves sending your QRDA III XML file to an endpoint (i.e. URL) that will then convert the file to QPP JSON, which is one of the two formats that the API accepts for submission. You can then submit the QPP JSON file to the API for submission and scoring purposes. For method one, your Registry, QCDR or EHR will generate the file and upload on your behalf. This means you will have to work with the 3rd party to identify workflows and timelines.

2. Manual upload via the QPP website – this workflow allows you to upload your QRDA III XML file for submission and scoring purposes. For method two, your EHR will need to be able to generate a QRDA III file in an XML file format. Some systems allow the end users to generate these files, while others require you to place a ticket to have one generated. You will want to work with your vendor to identify the process, timeline and capabilities of your EHR. Once you have your QRDA III file in hand, you can then submit it yourself by logging in to the submission portal at and uploading the document under the Quality submission category.

Once the file has been properly uploaded, either by using the manual upload or direct API submission methods, you should be able to see the details of that submitted file. We highly recommend verifying that your submission is correct: check that all desired quality measures have been reported on; and double check to make sure there are no apparent errors.

Questions? Contact our Quality experts or call us at 859-323-3090.


Year 3 of the Quality Payment Program (QPP) has seen substantial changes for the MIPS track across all four performance categories. The minimum threshold for the program increased from 15 to 30 points, making it essential to participate in more than one performance category to avoid a penalty.

The Quality performance category is very different for Year 3, including the expansion of flexibility under submission methods, restructuring of the Web Interface submission method, and the adoption of Facility-Based scoring, to name a few. This category is set to make up 45% of an Eligible Clinician’s or an Eligible Group’s MIPS final score, and requires a full 365 days of reporting. The weighting, paired with the reporting time frame, makes this category one of the most challenging. All of this makes it important to perform well on Quality for 2019.

Kentucky REC experts will interpret these changes and how they can impact your performance in 2019. We will explore the issues these changes present and what you can do to maximize your score for Year 3.

Webinar – QPP Year 3: Quality Category
Thursday February 21, 12:30 – 1:30 p.m. ET


ATTENTION PHYSICAL Therapists! QPP Webinar February 13


Kentucky REC quality experts and KPTA are hosting a webinar with guest expert Heather Smith of the American Physical Therapy Association. The information presented will help physical therapists understand the impact the Quality Payment Program will have on reporting requirements, payments, and services delivered for this year and the coming years.

Physical Therapy plays a critical role in a patient’s healing and quality of life after an injury or illness. Therefore, it should come as no surprise that CMS is extending its Quality Payment Program from previously included clinician types to physical therapists in Year 3. The QPP has already helped thousands of clinicians reduce costs, improve outcomes, and provide better care. Join us for this webinar, tailored to the specific needs and roles of physical therapists.

Webinar – Quality Payment Program 2019 – Helping Physical Therapists in the Value-Based Payment World

Wednesday February 13, 12:00 – 1:30 p.m. ET

Have questions? We’re here to help! Contact the Kentucky REC today or call us at 859-323-3090.


For all returning participants, the EHR reporting period is a minimum of any continuous 90 days between January 1 and December 31, 2019 for Meaningful Use measures. Medicaid EPs who are returning participants must report on a one year electronic Clinical Quality Measure reporting period, and first-time meaningful users must report on a 90-day electronic Clinical Quality Measure reporting period. EPs are required to report on any six eCQMs related to their scope of practice. In addition, Medicaid EPs are required to report on at least one outcome measure. If no outcome measures are relevant to that EP, they must report on at least one high-priority measure. If there are no outcome or high priority measures relevant to an EP’s scope of practice, they must report on any six relevant measures.

Good News: The list of available eCQMs for EPs in 2019 is aligned with the list of eCQMs available for Eligible Clinicians under MIPS in 2019. Those eCQMs can be found here. Electronic Clinical Quality Measures are expected to be reported by using a QRDAIII file for 2019.

All providers must attest to Stage 3 objectives and measures using 2015 EHR technology certified.

Have more questions? We are here to help! Contact the Kentucky REC today or call us at 859-323-3090 to learn more about the support we provide.

The Pill Podcast – Bonus Episode: QPP Year 3

In this special bonus episode of The PILL Podcast, Trudi Matthews interviews two of Kentucky Regional Extension Center’s subject matter experts, Robin Huffman and Kelly Fountain. These two quality experts break down the major changes to Year 3 in the Quality Payment Program. This overview will help our listeners understand the challenges they face under MACRA in 2019.

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 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.

Webinar Feb 12 – Patient Centered Medical Home and Specialty Practice: A Clear Roadmap for Practice Transformation

PCMH and PCSP are excellent practice transformation models for organizations committed to improving access, communication, and care coordination. PCMH and PCSP practices succeed in increasing quality outcomes, patient satisfaction, and cutting costs. Now is the perfect time to pursue recognition since your organization can also receive full points in the Improvement Activities category of the Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA).

Designed to accelerate your journey to PCMH/PCSP Recognition, our framework provides expert training, coaching, and resources. Your staff will be well prepared to carry out the practice transformation process within a 12-month period. Our webinar will discuss the possible financial benefits and other incentives of the PCMH/PCSP programs and our services.

Don’t miss the opportunity to be a part of something special as we work together to transform healthcare in Kentucky!

Webinar – PCMH & PCSP: A Clear Roadmap for Practice Transformation
Tuesday February 12th 12-1 p.m. ET