Merit-Based Incentive Payment System (MIPS) - Qualified Clinical Data Registry (QCDR)

What is MIPS and how does it impact me?

MIPS is the Merit-Based Incentive Program implemented by CMS to encourage reporting of quality metrics, demonstrating commitment to high quality, efficient care. It will measure Medicare Part B providers in four performance categories to derive a score that could affect a provider's Medicare reimbursement positively or negatively starting at 4% in 2019 (based on 2017 performance) and gradually increasing to 9% by 2022 (based on 2020 performance). In other words, the delta between penalties and incentives grows from 8% based on 2017 performance to 18% based on 2020 performance.

You can earn a positive payment adjustment from CMS based on evidence-based and practice-specific quality data reporting. Physicians who are required to participate in MIPS in 2017 who choose not to submit any data, may be penalized with a 4% Medicare pay cut in 2019.

What is a QCDR?

A Qualified Clinical Data Registry (QCDR) is an entity that collects medical or clinical data for the purposes of patient and disease tracking to foster improvement in the quality of care provided. CMS offers several reporting mechanisms – including QCDRs - for MIPS participation in 2018. The AHSQC has been approved by CMS as one such QCDR.  

AHSQC can directly submit your MIPS Quality data and quality Improvement Activities to CMS. AHSQC has also developed Non-MIPS measures which are more applicable to the care hernia surgeons provide demonstrate your commitment to quality hernia care.

Who can participate in MIPS?

MIPS Eligible Clinicians include Physicians, Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists who meet certain Quality Payment Program (QPP) criteria. AHSQC can only submit data for physicians who are active participants in the AHSQC.

To determine your participation status in the Quality Payment Program, please visit https://qpp.cms.gov (You’ll need to enter your NPI number).

When do I have to submit my data?

The Quality Payment Program has already begun. The performance period is January 1, 2018 to December 31, 2018 for the 2019 payment adjustment. You can choose to start reporting anytime between January 1, 2018 and October 2, 2018 to achieve a 90-day performance period. The AHSQC must submit your data to CMS by March 31, 2019.

What measures are being submitted?

If you choose to submit data via the AHSQC as a QCDR, you will be given a list of measures to consider. The AHSQC has both MIPS and Non-MIPS measures available. As a registry, we already collect this data for you within the AHSQC. You can view the list of measures below. 

Does AHSQC allow me to report as a group or as an individual?

The AHSQC allows participants to report data only as an individual (defined as a single NPI tied to a single Tax ID number). By submitting as an individual, your payment adjustment will be based on your specific performance.

Will the data I report be made public?

Yes, measures reported as part of the MIPS program may be publicly reported on the Physicians Compare website.   

Currently your data (or your institution’s data) is not reported publicly.  If you choose to utilize AHSQC to submit your MIPS data to CMS on your behalf, you will need to sign an agreement with AHSQC which includes consent to release your data for public reporting. It is up to you to obtain any approvals within your practice or institution necessary to allow public reporting of data.

How much data do I have to submit?

You can choose to submit as little or as much data as you wish. MIPS offers 3 options on the ‘pace’ you want to submit:

Test Pace – Submit some data after January 1, 2018 that will result in a neutral or small payment adjustment. This can be as simple as submitting one measure for one patient or one improvement activity through the AHSQC QCDR.

Partial Pace – Report for a 90-day period after January 1, 2018 that will result in a small positive payment adjustment.

Full Pace – Fully participate starting January 1, 2018 that will result in a modest positive payment adjustment. Full reporting includes submission of required measures and activities in all 3 performance categories: quality, improvement activities, and advancing care information. You will report for a full year (or at least 90 days).

I’d like AHSQC to submit my data for MIPS.  What do I do now?

If you are an active participant in good standing and have confirmed your eligibility to participate in MIPS for 2018 (see above link), and you would like AHSQC to submit data on your behalf, please contact Shelby Dunstan (Shelby@ahsqc.org). 

We will work with you and our data vendor, ArborMetrix, to determine the approach you’d like to take and which data you wish to be submitted. You must reach out to Shelby no later than January 31, 2019 to meet all deadlines. 

The AHSQC has been approved as a 2018 Qualified Clinical Data Registry (QCDR) for the Merit-Based Incentive Payment System (MIPS).

View 2019 AHSQC Measures

View 2018 AHSQC Measures

View 2017 AHSQC Measures

42,042 Enrolled Patients

320 Participating Surgeons