HSAG engages providers at all levels of performance for collaborative learning and action that accelerate healthcare quality improvement. Use the resources below to better understand and successfully implement the Quality Payment Program (QPP).
Merit-based Incentive Payment System (MIPS) Overview
- Overview of the Quality Payment Program
- Impact of MIPS Participation on Medicare Reimbursements
- Comparison of MIPS Year 2 (2018) and Year 3 (2019) Requirements
- FAQs for QPP Year 3 (2019)
- 2019 Facility-based Measurement Fact Sheet
- 2019 MIPS Reporting
- 2019 MIPS Opt-In and Voluntary Reporting Policy Fact Sheet
- 2019 Facility-based Preview FAQs
- 2019 MIPS Quick Start Guide
- 2019 MIPS Participation and Eligibility Fact Sheet
- 2019 MIPS Tips for Successful Participation
- Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) User Guide (ZIP)
- 2019 Year 3 Countdown to MIPS Data Submission
- 2019 MIPS Participation Determination
- 2019 QPP Documents for an Audit
- No-EHR MIPS Action Plan
Quality Performance Category
- 2019 Quality Fact Sheet
- 2019 Quality Benchmarks (ZIP)
- 2019 Claims Data Submission Fact Sheet
- 2019 Quality Data Submission Criteria
- 2019 Cross-Cutting Quality Measures
- 2019 Medicare Part B Claims Measure Specifications and Supporting Documents (ZIP)
Promoting Interoperability (PI) Performance Category
- 2019 PI Fact Sheet
- 2019 PI Information Blocking Fact Sheet
- 2019 PI Measure Specifications (ZIP)
- Security and Risk Assessment Webinar (February 22, 2019)
- Provider EHR Complaint Process
Improvement Activities (IA) Performance Category
Cost Performance Category
Data Submission Resources
YouTube Videos on Data Submission
- Navigation to Individual and Group Submission (3:56)
- Uploading Files (1:44)
- Reviewing Overview Data (2:33)
- Reviewing Quality Category Data (4:47)
- Reviewing Promoting Interoperability Category Data (3:22)
- Manual Attestation of the Promoting Interoperability Category (5:10)
- Reviewing Improvement Activities Category Data (2:31)
- Manual Attestation of the Improvement Activities Category (3:27)
- Reviewing and Submitting Data as a Registry (9:23)
- Deleting Submitted Data (4:04)
For up-to-date information and guidance on QPP reporting, visit our Learning Forum Friday webpage for registration to our live training webinars and for access to our web recording archive.
QPP and Merit-based Incentive Payment System (MIPS)
- What is the Quality Payment Program? (2:30)
- Introduction to MIPS —2018 (3:40)
- MIPS 101 for the 2019 Performance Year —2019 (1.17 hours)
- Quality Payment Program Year 3 (2019) Final Rule Overview webinar —2019 (1.37 hours)
- Public Reporting on Physician Compare: What You Need to Know —2018 (20:59)
- Eligiblity Dashboard Demonstration —2018 (1:40)
- How to Access Performance Feedback for Individuals —2018 (9:00)
- How to Access Performance Feedback for Voluntary Submitters —2018 (3:45)
- Introduction to Advanced Payment Models (APMs) (5:50)
- MIPS APMs (Online course from Medicare Learning Network, offering .5 AMA PRA Category 1 Credits)
- What are the criteria for APMs? (13:00)
- What is a Qualifying APM Participant? (13:45)
- How to Access Performance Feedback for APM Entities —2018 (7:00)
- MIPS Quality Performance Category Overview for Year 3 (2019) —2019 (1.03 hours)
- MIPS Promoting Interoperability webinar —2018 (1 hour)
- 2018 Cost Performance Category webinar —2018 (1 hour)
Creating a HARP Account for QPP
(HARP = Healthcare Quality Information System [HCQIS] Access Roles and Profile)
HSAG has assembled important Merit-Based Incentive Payment System (MIPS) Quality measure-related resources to help you stay on track. Start here at the CMS Centralized Repository that provides a list of specialized and other registries.
- Anesthesiology: MIPS Quality Measures from the American Society of Anesthesiologists (ASA)
- Cardiology: Cardiology Quality Measures handout
- Emergency Medicine: MIPS Measures Relevant to Emergency Medicine
- Obstetrics/Gynecology (OBGYN): MIPS Measures Relevant to OBGYN
- Optometry: 2018 Optometry MIPS Quality Measure Recommendations
- Orthopedic Surgery: MIPS Measures Relevant to Orthopedic Surgery
- Podiatry: Clinical Quality Measures for Podiatrists
- Psychiatry: MIPS Quality Performance Category: 2018 Performance/2020 Payment the American Psychiatric Association (APA) (available as a downloadable fact sheet)
- Radiology: 2018 MIPS Measures Relevant to Radiologists
- Urologists: 2018 MIPS Toolkit from the American Urological Association
HSAG has assembled helpful IA-based resources and tools to assist you.
- MIPS Improvement Activities Fact Sheet
- Prescription Drug Monitoring Program (PDMP) Training and Technical Assistance Center—Obtain PDMP-related information, including where to find your PDMP by state.
- High Priority IA: Clinicians would attest that 60 percent for the first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of Controlled Substance Schedule II (CSII) opioid prescription that lasts longer than three days.
- Medium Priority IA: Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS-eligible clinicians and groups must participate for a minimum of six months.
- Improvement Activities related to California PDMP (known as CURES)
- Radiology: 2018 MIPS Improvement Activities from the American College of Radiology
HSAG encourages your use of the following resources to help guide your understanding of PI (formerly known as ACI).
- PI Fact Sheet
- CMS Centralized Repository provides a list of specialized and other registries
- Patient Engagement Playbook from the Office of the National Coordinator (ONC)
- How to Get Your Patients to Use the Patient Portal webpage from p3Inbound
Practices using health information technology, including electronic health records (EHR), are required to conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process. Providers are under a duty to protect data in accordance with security risk analysis. The guidance below offers ways to help keep your data safe from a ransomware attack and what to do if an attack occurs.
If You Are a Victim of an Attack
If your organization is the victim of a ransomware attack, Health and Human Services (HHS) recommends the following steps:
- Please contact your FBI Field Office Cyber Task Force (www.fbi.gov/contact-us/field/field-offices) immediately to report a ransomware event and request assistance. These professionals work with state and local law enforcement and other federal and international partners to pursue cyber criminals globally and to assist victims of cyber-crime.
- Please report cyber incidents to the U.S. Computer Readiness System (US-CERT) (www.us-cert.gov/ncas) and FBI’s Internet Crime Complaint Center (www.ic3.gov).
- **NEW** If your facility experiences a suspected cyberattack affecting medical devices, you may contact FDA’s 24/7 emergency line at 1.866.300.4374. Reports of impact on multiple devices should be aggregated on a system/facility level.
- For further analysis and healthcare-specific indicator sharing, please also share these indicators with HHS’ Healthcare Cybersecurity and Communications Integration Center (HCCIC) at HCCIC@hhs.gov.
How to Mitigate Against an Attack
- Educate users on common Phishing tactics to entice users to open malicious attachments or to click links to malicious sites.
- Patch vulnerable systems with the latest Microsoft security patches: https://technet.microsoft.com/en-us/security/bulletins.aspx.
- Verify perimeter tools are blocking Tor .Onion sites.
- Use a reputable anti-virus (AV) product whose definitions are up-to-date to scan all devices in your environment in order to determine if any of them have malware on them that has not yet been identified. Many AV products will automatically clean up infections or potential infections when they are identified.
- Monitor the US-CERT website for the latest updates from the U.S. government. See below for current reporting.
- Utilize HPH Sector Information Sharing and Analysis Center (ISAC) and Information Sharing and Analysis Organization (ISAO) resources. See below for further information.
Original release date: June 27, 2017 US-CERT has received multiple reports of Petya ransomware infections occurring in networks in many countries around the world. Ransomware is a type of malicious software that infects a computer and restricts users' access to the infected machine until a ransom is paid to unlock it. Individuals and organizations are discouraged from paying the ransom, as this does not guarantee that access will be restored. Using unpatched and unsupported software may increase the risk of proliferation of cybersecurity threats, such as ransomware.
Petya ransomware encrypts the master boot records of infected Windows computers, making affected machines unusable. Open-source reports indicate that the ransomware exploits vulnerabilities in Server Message Block (SMB). US-CERT encourages users and administrators to review the US-CERT article on the Microsoft SMBv1 Vulnerability and the Microsoft Security Bulletin MS17-010. For general advice on how to best protect against ransomware infections, review US-CERT Alert TA16-091A. Please report any ransomware incidents to the Internet Crime Complaint Center (IC3).
Sector ISAO and ISAC Resources
National Health Information-Sharing and Analysis Center (NH-ISAC) has shared the following TLP-White Message and will continue to share information at nhisac.org. Health Information Trust Alliance (HITRUST) has shared the following Threat Bulletin for distribution.
Office of the National Coordinator (ONC) and Office for Civil Rights (OCR) Resources
- ONC provides many helpful resources about Health IT Security to include cybersecurity guidance materials and training at https://www.healthit.gov/topic/privacy-security-and-hipaa/health-it-privacy-and-security-resources-providers and https://www.healthit.gov/providers-professionals/ehr-privacy-security/resources.
- OCR provides cybersecurity guidance materials including a cybersecurity checklist, ransomware guidance and cyber awareness newsletters at https://www.hhs.gov/hipaa/for-professionals/security/guidance/cybersecurity/index.html.
From time to time, resources are from CMS and are updated and posted regularly as new updates come online.
HSAG has gathered relevant QPP materials and tools into one place. In addition, download a handy graphic icon for conversion into a desktop widget by following easy step-by-step instructions. To get started, review these essential tools for your state:
2018 QPP Guide (PDF)
QPP Audit Resource (PDF)
Other Helpful Resources
The Centers for Medicare & Medicaid Services (CMS) have assembled QPP-related resources at https://qpp.cms.gov/about/resource-library. These materials include a MIPS Activity Fact Sheet, MIPS participation Fact Sheet, and MIPS 2018 CMS-Approved Qualified Registries Guide.
Be sure to visit these CMS resources:
- 2017 MIPS Performance Feedback User Guide
- 2017 MIPS Performance Feedback Fact Sheet
- CMS Guide for Obtaining a HARP Account for the QPP
- 2018 Registration Guide for the Web Interface and CAHPS* for MIPS Survey
- CMS Web Interface Fact Sheet
- MIPS Participation & Overview Fact Sheet
- Hardship Exception Application Forms for 2018 Payment Adjustment
- QPP Final Rule 2019
* CAHPS = Consumer Assessment of Healthcare Providers and Systems
* HARP = Health Care Quality Information System (HCQIS) Access Roles and Profile System