MACRA Minute September Newsletter


Don’t Fall Behind

Fall is almost here…If you haven’t spoken with our staff regarding your plan for participation in the Quality Payment Program/Merit-Based Incentive Payment System (QPP/MIPS), NOW is the time!

For example, if you plan to submit MIPS data for a 90-day time frame, the last day to begin is October 2. Please call 844-358-4021 or send us an email. An advisor will be available to answer your questions and discuss next steps based on your goals. Don’t delay!

Deadline: Last Call for Improvement Activities

To attest to completion of an Improvement Activity(ies), clinicians must start implementing the activity no later than October 2nd to allow for the minimum 90 days of implementation.To attest to completion of an Improvement Activity(ies), clinicians must start implementing the activity no later than October 2nd to allow for the minimum 90 days of implementation.

What This Means: If you haven’t done so already, begin choosing your activities to achieve full credit in this category toward your MIPS score. For more information, contact a Telligen Advisor.

Your Action Items:

  1. Decide now which activity you will implement.
  2. Determine how to gather the required documentation you will keep for six years in the event of an audit.

Available Resource: The CMS guide, “MIPS Data Validation Criteria,” will walk you through the supporting documentation requirements.

  • Use the spreadsheet to find documentation examples for each activity.
  • Review the activity’s description in full detail to ensure there’s enough time to implement (for example, annual registration in the prescription drug monitoring program requires six months).

Coming Soon: 2016 QRUR Reports

This Fall, CMS will provide access to 2016 Quality & Resource Use Reports (QRURs) to nationwide group practices and solo practitioners subject to the Value Modifier (VM).

In addition to groups and solo practitioners, QRURs will be available to 2016 participants in the Medicare Shared Savings Program, the Pioneer ACO Model, the Next Generation ACO Model, the Oncology Care Model, the Comprehensive ESRD Care Model, the Comprehensive Primary Care initiative.

Who’s Subject to the VM? Clinicians subject to the VM are identified in the QRURs by their Medicare-enrolled Taxpayer Identification Number (TIN).

What’s in the Report? The report will show how groups and solo practitioners performed in 2016 on the quality & cost measures used to calculate the 2018 VM, & how the VM will apply to payments under the 2018 Medicare Physician Fee Schedule for clinicians billing with the QRUR TIN.

Where Can I Access the Report? Authorized representatives of groups & solo practitioners can access QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management account with the correct role. For more information on accessing the 2016 Annual QRURs, please visit How to Obtain a QRUR.

Complete List of QRUR Resources

How to Understand Your 2016 Annual QRUR: How to use the report & accompanying tables to understand performance & identify improvement opportunities.

Quality Benchmarks for the 2018 VM & the 2016 Annual QRURs: How to compare performance on each of the quality measures against solo & group practices nationwide.

  • Outlines quality benchmarks that: 1) represent the means & standard deviations for each measure; 2) were used to calculate the 2018 VM.
    • The benchmarks are based on performance of nationwide solo & group practitioners in 2015 (2015 benchmarks = 2016 performance year).
  • A group or solo practitioner’s individual measure score – part of the overall quality composite for the VM – depends on the performance rate relative to the benchmark for that measure.

Fact Sheet: Attribution in the 2018 Value Modifier: Outlines the two-step attribution methodology for claims-based quality outcome measures & per capita cost measures included in the 2018 VM.

Fact Sheet: Specialty Adjustment in the 2018 VM: Outlines the specialty adjustment methodology used in the 2018 VM.

Fact Sheet: Risk Adjustment in the 2018 VM: Outlines the risk adjustment methodology used in the 2018 VM.

Measure Information: 30-Day All-Cause Hospital Readmission Measure: Overview of the 30-Day All-Cause Hospital Readmission measure calculated for the 2018 VM.

Measure Information: Ambulatory Care-Sensitive Condition (ACSC) Composite Measures: Overview of the hospital admissions for ACSC measures calculated for the 2018 VM.

Measure Information: Total Per Capita Cost Measure: Overview of per capita costs for all attributed beneficiaries measure calculated for the 2018 VM.

Events: Mark Your Calendar

Thursday, September 28

Telligen QPP-SURS Webinar: MIPS Calculator Demonstration 

Thursday, September 28 from Noon to 1 p.m., CST

Do You Know . . .

  • How CMS calculates final MIPS scores?
  • Where scores are publicly reported for prospective patients & peers to see?

We want to help . . .

Clinicians have a better understanding of the components that factor into your MIPS final score.

Here’s How:

Kaitlin Nolte from Great Plains QIN-QIO will introduce a new calculator for estimating the financial impact of your final MIPS score. Advisors from Telligen will also provide example scenarios for different practices sizes. Click here to register.

Tuesday, September 12 or Thursday, September 14

National LAN Webinar: Choosing Quality & Improvement Activities for MIPS Reporting

To be eligible for an incentive payment, clinicians need to report quality measures and quality improvement activities for 2017. This webinar will pool advice from quality improvement advisers dedicated to helping small group practices transition to MIPS. Participants will learn:

  • How to evaluate the pros and cons of choosing particular quality measures
  • Whether reporting on your best measures or all available measures is the better strategy
  • How to “attest” to participating in quality improvement activities
  • What to do if you have yet to select quality measures or begin improvement activities
  • Where to find FREE technical assistance and other resources to help make decisions about your quality measures or improvement activities

Registration Instructions:

This event will feature an expert panel discussion and participant Q&A session. To accommodate schedules and time zones, two sessions are available. Please register by clicking on the date you plan to participate.

Tuesday, September 12 at 11 a.m., EST

Thursday, September 14 at 3:30 p.m., EST

In Case You Missed It…

Telligen QPP-SURS Webinar: Looking Ahead to Year 2

Understand proposed changes for QPP Year 2 (2018), & evaluate their potential Impact.

National LAN Webinar: The Mechanics of Data Submission

Outlines pros & cons for different QPP data submission types, including: claims, EHR, qualified clinical data registry, & qualified registry

Attention: Small, Undeserved, & Rural Providers

CMS is looking for volunteers to test the QPP website, & wants small, underserved, and rural practices to be heard. Help them out by volunteering to participate, &/or spreading the word to your contacts & colleagues.

  • Purpose: Help CMS determine whether the QPP website is meeting goals to: 1) provide clinicians streamlined access to information; 2) minimize undue burdens for program participation.
  • Audience: CMS invites representatives from organizations of all sizes to assess current and functionality of the website, & make recommendations for improvements. CMS is looking for:
    • Medicare clinicians
    • Practice managers
    • Administrative staff
    • EHR & registry vendors

Sign-Up: Email CMS to participate in a one-on-one feedback session. Also, please also notify us at so we can highlight your participation in our monthly report to CMS.

Take Action: EHR Vendor Issues

We recognize EHR vendor issues can be a barrier to achieving QPP goals, & encourage clinicians to create awareness by reporting issues using the processes outlined below.

If you have unresolved complaints about your EHR vendor or you feel the Office of the National Coordinator for Health IT (ONC) needs to be aware of a situation, the following actions items are available:

  1. Send your complaints to the ONC-ACB that certified the product
  2. Complete the ONC’s complaints form

To Find the ONC-ACB that Certified the Product: Go to the Certified Health IT Product List (CHPL) website, find your product, & click ‘details’ to the right.

You will see several different items on the page, including ONC-Authorized Certification Body with the name of that body. You can then reach out to that body using the following email addresses:

This information can be found at:


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