CMS recently distributed a notice to some EHR and Qualified Clinical Data Registry (QCDR) vendors regarding CMS’ discovery of various data errors submitted on behalf of eligible professionals (EPs) and group practices (GPROs), including, but not limited to, missing or incorrect performance rates, missing or invalid numerator data, missing or invalid denominator data, and calculation errors. Due to these findings, CMS will not be able to use these data to determine quality performance and/or establish benchmarks for the 2014 reporting year.
CMS lays out the following action plan for each of the quality reporting programs.
Because PQRS is a pay-for-reporting program, CMS is able to use these data for purposes of assessing PQRS satisfactory reporting provided that all identifying information (TIN/NPI data) was submitted correctly and accurately. Therefore, group practices and EPs reporting to PQRS through an EHR or QCDR will be assessed based on the data CMS received. The Physician Quality Reporting Incentive Feedback Individual Performance Report will include the performance data at the NPI level. This report will be available on the CMS Enterprise Portal. EPs do not need to file an informal review based on the performance data shown in these reports. CMS did not specify when these reports will be available.
EHR Meaningful Use Incentive Program
CMS is able to use these data for purposes of assessing EPs for meeting the Clinical Quality Measure (CQM) reporting requirements of the EHR Incentive Program provided that all identifying information (TIN/NPI data) was submitted correctly and accurately. Therefore, EPs who electronically submitted their CQMs through the Quality Net Portal will be assessed based on the data CMS received.
Value-Based Payment Modifier
Vendor errors may impact the calculation of quality scores and in ascertaining whether quality measures were reported. Specifically, CMS will not be able to accurately calculate the PQRS portion of the Quality Composite Score and will therefore base the score solely on the claims based outcomes measures and CAHPS (if applicable). However, if it is determined that calculating the Quality Composite Score based solely on the claims based outcomes measures and CAHPS survey measures results in the TIN being scored as low quality for purposes of calculating the VM, the TIN will instead be considered average.
Physician Compare Impact
Given that analyses to date indicate these data do not meet the public reporting standards of being valid, reliable and comparable, 2014 EHR data will not be publicly reported on Physician Compare.
ASCRS•ASOA will be working with the AMA and others in the medical community to work with CMS on this issue and prevent future occurrences.
If you have questions, please contact Ashley McGlone at firstname.lastname@example.org or 703-591-2220.