Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

OIG: Practice Aid, QPP Integrity Needed for MACRA Implementation

OIG identified MACRA implementation vulnerabilities, including a lack of practice-specific assistance and QPP integrity plan to prevent fraud and improper payments.

MACRA implementation and the Quality Payment Program (QPP)

Source: Thinkstock

By Jacqueline LaPointe

- A recent Office of the Inspector General (OIG) investigation found two major vulnerabilities with MACRA implementation. The HHS watchdog reported that CMS still needs to provide practice-specific technical assistance and implement a Quality Payment Program (QPP) integrity strategy to prevent Medicare fraud and improper payments.

“If clinicians do not fully understand how to participate in the QPP, or if they lack the tools and support to make the practice changes necessary to respond to QPP incentives, the program may have limited success,” OIG wrote. “Additionally, without adequate program integrity measures in place, the performance data submitted may not reflect the true cost or quality of care provided, similarly compromising the QPP’s ability to achieve its goals.”

With regards to QPP technical assistance, the investigation showed that CMS successfully increased clinician awareness of the QPP through general outreach campaigns.

The federal agency reached about 176,000 individuals, including clinicians, practice managers, and vendors, through 631 outreach events as of September 2017. The events included webinars, speeches at medical association meetings, in-person regionally-based educational initiatives, and town hall listening sessions.

CMS also partnered with medical associations and other industry groups to provide clinician training and appointed 12 Clinician Champions who distributed QPP knowledge to peers and provided CMS with clinician feedback.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

A CMS survey in the spring of 2017 showed improvements in clinician awareness of the QPP and MACRA implementation. The survey uncovered high levels of awareness (71 percent) among practice managers, but lower levels among clinicians (60 percent) and mid-level practitioners (44 percent).

While general QPP awareness increased compared to previous CMS surveys, respondents still expressed confusion over the Advanced APM and Merit-Based Incentive Payment System (MIPS) tracks.

The finding echoed other recent surveys that found clinicians and practice managers know of the QPP, but most cannot correctly identify MIPS data submission requirements or payment adjustments.

Despite lackluster awareness and understanding, about 63 percent of respondents still anticipate reporting to the QPP in 2017. However, CMS may not achieve its goal of 90 percent participation based on the responses from survey participants.

Practice-specific technical assistance may help CMS to increase QPP participation and help clinicians in small and rural practices succeed under the new program, OIG stated.

READ MORE: CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation

As part of MACRA implementation, CMS created the following technical assistance groups to help clinicians in specific practice settings with the QPP:

• 11 QPP Small, Underserved, and Rural Support (QPP-SURS) contractors that serve small practices and clinicians practicing in rural and medically underserved areas

• 14 Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs) that help large practices of 15 or more clinicians

• 41 Transforming Clinical Practice Initiative (TCPI) cooperative agreement grantees that aid clinicians with practice transformations that align with MIPS incentives and eventually alternative payment model adoption

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

CMS designed the three technical assistance groups to provide specialized, practice-specific assistance. However, only about 25 to 30 percent of QPP-SURS and QIN-QIO efforts were specialized technical assistance focusing on practice-specific needs, OIG reported.

QPP-SURs also only reached 37 percent of the eligible clinicians in their jurisdictions as of Aug. 31, 2017.

“CMS needs to continue to assess progress and increase the proportion of contractors’ efforts devoted to specialized technical assistance to support high levels of clinician participation,” the HHS watchdog advised. “Small practices and clinicians in rural or medically underserved areas, who may have fewer administrative resources and less experience with prior CMS quality programs, should be prioritized for assistance.”

Additionally, the OIG investigation revealed that the lack of QPP integrity strategy was an emerging MACRA implementation vulnerability.

“To ensure that the QPP succeeds, CMS must effectively prevent, detect, and address fraud and improper payments,” the report stated. “QPP payment adjustments are intended to reward high-value, high-quality care. Safeguarding the validity of MIPS data and the accuracy of QPP payment adjustments is critical to ensure that these payments are based on clinicians’ actual performance.”

CMS has already included oversight provisions in the 2017 final MACRA implementation rule and established an oversight process for CMS-approved vendors, OIG acknowledged. However, the federal agency has yet to appoint leadership for program integrity and create a comprehensive program integrity plan.

OIG stated that the QPP integrity plan needs to address potential vulnerabilities in the MIPS data submission system. The system aims to provide eligible clinicians with real-time feedback on how the data submitted could impact composite MIPS scores. Clinicians can also use the system to resubmit data that will supersede previous submissions.

While these system components improve feedback and allow clinicians to correct data errors, they could also make it easier for clinicians to game the submission system to boost their MIPS scores, the HHS watchdog explained. Higher MIPS scores may result in greater payment adjustments.

For example, clinicians will check a series of boxes to certify EHR use under the Advancing Care Information category of MIPS. When clinicians complete the list, the system will provide a real-time score that shows if the clinician earned maximum points.

Clinicians will be able to go back to the checklist and submit different answers if the clinician is not satisfied with the initial score.

OIG warned CMS that the system’s resubmission feature could be abused if clinicians submit inaccurate data just to boost their points.

CMS responded that officials will be able to view how and when clinicians change their MIPS data submissions. But OIG noted that the lack of program integrity expert advice during system design and a comprehensive program integrity plan still put the QPP at risk for fraud and improper payments.

The QPP integrity plan must also address the accuracy of MIPS data submitted by clinicians, the OIG added.

In 2017, CMS explained that its data validation efforts targeted clinicians who submitted fewer than the required number of quality measures. The QPP data submission system also includes data validation functions.

However, OIG reported that the automated checked only identify incorrect file formats and quality measures that do not make sense, such as a reported quality measure with a numerator greater than the denominator.

The automated data validation checks cannot determine whether incorrect or falsified information was submitted. CMS depends on the certification of clinicians or their authorized vendors to submit accurate, true data, the report stated.

Relying on clinicians to submit accurate data has been an issue for CMS programs in the past. The Medicare EHR Meaningful Use program allowed clinicians to self-attest for certain items. But OIG discovered that CMS paid about $729 million in improper incentive payments to eligible professionals who did not comply with program requirements.

The improper payments happened because CMS performed minimal documentation reviews of self-attestation. Providers also did not have sufficient support for their attestations.

Advancing Care Information replaced the Meaningful Use program and the MIPS category faces similar data validation issues, OIG stated. The MIPS Improvement Activities category also contains similar fraud, abuse, and improper payment vulnerabilities because the category is based on self-attestation.

CMS should develop a robust audit strategy to review the accuracy and validity of MIPS data as part of its comprehensive QPP integrity plan, OIG advised.

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