Final 2020 MIPS Submission Data Review

Your final 2020 MIPS Group and Individual submission data has been compiled corresponding to your Organization Tax Identification Number(s) (TIN) and for each provider’s individual National Provider Identifier (NPI) associated with the TIN. This data will be submitted to CMS pending certification of your reporting type. Please note, individual patient data is not submitted to CMS as part of this process. The final 2020 MIPS submission data should be reviewed carefully to confirm your reporting type and your intent for Keet Health to submit your MIPS data to CMS on your behalf for the 2020 MIPS performance year. 

To finalize your 2020 MIPS submission, review the final 2020 Group and Individual MIPS submission data published within the Keet Outcomes Dashboard. Once complete, submit the 2020 MIPS Submission Attestation Form to certify your reporting type and intent for Keet Health to submit your MIPS data to CMS.

 

Report Components & Definitions 

Component

Definition

Performance Rate Report by Organization (Functional & Pain Measures)

This report is located on the Performance Reports tab of the Keet Outcomes Dashboard and includes the overall 2020 performance data at the Organizational TIN level.  This data will be submitted to CMS if you select the following reporting types: Group or Both.

Performance Rate Report by Practitioner (Functional & Pain Measures

This report is located on the Performance Reports tab of the Keet Outcomes Dashboard and includes the 2020 performance year data for each Individual NPIs associated with your TIN. This data will be submitted to CMS if you select the following reporting types:  Individual or Both.

Compliance Rate

This report is located on the Process Reports tab of the Keet Outcomes Dashboard and shows the proportion of eligible patients that were evaluated for MIPS reporting. For the 2020 performance year, Keet requires that at least one PRO is collected on a minimum of 70% of eligible patients.

Measure

Acronym for the patient reported outcome (PRO) measure and the measure's corresponding pain scale. 

Measure ID

Established CMS MIPS quality measure number.

Eligible Population

Number of patients who were evaluated for the corresponding measure and were 18 years or older during the performance year.

Eligible Population Exclusion

Number of eligible patients who completed less than 2 PRO surveys for the corresponding measure. 

Eligible Population Exception

Number of eligible patients identified as disqualified in accordance with the CMS guidance criteria

Measure Population

Number of eligible patients minus the exclusion and exception population. This is the denominator for the measures Failure to Progress (FTP) rate.

Progressed Population

Number of patients who met the measure Minimal Clinically Important Difference (MCID).

FTP Population

Number of patients who failed to meet the measure MCID. This is the numerator for the measures FTP rate.

Outperforms 2019 Benchmark

Performance indicator displaying whether the FTP rate for the measure is less than the 2019 MIPS Performance Year benchmark. If your FTP rate is lower than the performance benchmark, TRUE. If your FTP rate is higher than the performance benchmark, FALSE.

FTP Org/Practitioner

Proportion of patients who failed to meet the measure MCID. The FTP rate will be compared to the 2020 established benchmark for the measure. 

Benchmark FTP Percent

2019 Performance Benchmark for that measure.

Predicted FTP Org

Performance indicator displaying the proportion of patients that based on statistical predictive modeling were expected to fail to show progression.

Performance Rate Difference Org

Difference between the observed FTP rate and the Predicted FTP rate. A negative number is an indicator of positive performance.

Outperforms Predicted Benchmark

Performance indicator displaying whether the FTP rate for the measure is less than the Predicted FTP rate. If less, TRUE. If more, FALSE.

Meet Case Req

For the 2020 MIPS performance year, a minimum of 20 cases are required per measure. True indicates that the 20 case minimum requirement was met for the measure. False indicates that the 20 case minimum requirement was NOT met for the measure. 

   

 

Review Your Final 2020 MIPS Submission Data

Review the following steps for both the Group and Individual reports to determine your intent to report and reporting type for the 2020 MIPS performance year.

Additional information on reviewing your performance can be found in the Keet Outcomes Dashboard education series under “Performance Reports”.

 

How is scoring impacted if the 70% Compliance Rate or 20 Case Minimum requirement is not met? 

Outlined below are the 3 scenarios used to calculate the scoring for each outcome measure:

2020_Scoring_Scenarios.JPG

Determine Your 2020 Report Type

Review this article for information on the individual, group, or both reporting type options. Additionally, find more information on reporting types at the Quality Payment Program website.

 

Confirm Your 2020 MIPS Reporting

Following review of your 2020 Final MIPS Submission Data, submit the 2020 MIPS Final Submission Attestation Form to confirm your intent for Keet Health to submit your MIPS data to CMS. Please note, if you are submitting data for multiple TINs, a separate 2020 MIPS Final Submission Attestation Form must be completed for each distinct TIN.

 

2020 Final MIPS Submission Data Review FAQs

Do these reports include the CMS benchmark I will be graded against? 

No, Medicare will calculate the benchmark for 2020 after all data has been submitted. 

 

Why are there only 5 PRO measures by TIN and Individual NPI?

The PRO measure is actually listed twice once for the PRO measure and again for the corresponding PRO numeric pain scale rating (NPRS).  You may need to scroll within the Performance Report to view the pain measures.

  • KOS - IROMS 11
  • KOS NPRS - IROMS 12
  • LEFS- IROMS 13
  • LEFS NPRS- IROMS 14
  • NDI- IROMS 15
  • NDI NPRS- IROMS 16
  • MDQ- IROMS 17
  • MDQ NPRS- IROMS 18
  • DASH- IROMS 19
  • DASH NPRS- IROMS 20

What Improvement Activities are reported? 

Keet helps you achieve the maximum available points for the Improvement Activities category by satisfying and reporting on the following measures:

  • Participation in a QCDR, that promotes the use of processes and tools that engage patients for adherence to treatment plans.
  • Collection and follow-up on patient experience and satisfaction data on beneficiary engagement.
  • Participation in a QCDR, that promotes the use of patient engagement tools.

Can Keet review my data to tell me how to report or assess my performance?

No, we cannot advise on specific performance or decisions other than to offer the guidance and process requirements documented by CMS. For more information on how MIPS Quality Measures are scored, CMS has provided the 2020 MIPS Scoring Guide.