QE101: Introduction to the Qualified Entity (QE) Program

March 22, 2013

Today’s Objectives

Introduce QE Program and its missionIntroduce QECP and its activitiesDescribe QE requirements and their derivationDescribe methods for determining and ensuring compliance with requirements

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QE Medicare Data Sharing Program: What it is?

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Under section 10332 of the Affordable Care Act, beginning January 1, 2012, CMS is required to make standardized extracts of Medicare Parts A, B, and D data available to “qualified entities” for the purposes of evaluation and reporting on the performance of healthcare providers and suppliers.

QE Program

Core Principles:• Beneficiary privacy and

data security• Valid and reliable

measurement• Fair and comprehensive

provider performance reporting

Enables QEs to:• Combine Medicare

claims data with data from other payer sources to evaluate provider performance

• Produce, and make available to the public, comparative reports summarizing provider performance

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QE Medicare Data Sharing Program: Mission

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“To improve the quality and reduce the cost of healthcare nationwide by enabling better, more comprehensive provider performance reporting through access to Medicare fee-for-service and Part D Event data. We aim to improve the quality of provider performance, increase transparency in healthcare performance, provide information for employers and consumer groups to make more informed healthcare decisions, and spur innovation in the area of performance measurement.”

QE Medicare Data Sharing Program: How it Achieves its Mission?

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QEs must provide reports to the public at least once per year

These reports provide: Comprehensive and fair provider comparisons Analyses of providers and suppliers that can

inform health care networks and pay-for-performance programs

Actionable performance reports for providers and consumers

QE 101 Webinar

Qualified Entity Certification Program (QECP): What it is?

The QECP uses a core set of rigorous, comprehensive criteria to evaluate an organization’s ability to become a CMS-approved QE.

The program provides support and oversight to organizations interested in becoming QEs, throughout the application and evaluation process, and following approval.

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QECP Requirements

Based on the Medicare Data Sharing Program Final Rule, released on Dec 7, 2011, the QECP developed a set of minimum requirements for all QEs

All requirements of this program can by traced back to 3 key tenants of the QE Program: 1: Data Security – keeping beneficiaries’ protected health information secure; 2: Valid and Reliable Measurement; and 3: Fair and Comprehensive Provider Reporting

There are 8 program standards and 24 corresponding elements

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QE 101 Webinar

QECP Application Standards

Standard 1: Applicant Profile Standard 2: Data Sources Standard 3: Data Security Standard 4: Methodology for Measurement &

Attribution Standard 5: Measure Selection Standard 6: Verification Process Standard 7: Reporting of Performance Information Standard 8: Corrections/Appeals

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Determining Compliance with Requirements

Four-phased Minimum Requirements review Phase 1 establishes an applicant’s business

organization, their intended use of Medicare data, ability to fund QE business operations, and the additional source of payer claims data required

The remaining three phases focus on assessing a QE’s compliance with the three core tenants of the QE program: data security, valid and reliable measurement, and comprehensive provider reporting

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QECP Application Process 2012/2013

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Ensuring Ongoing Compliance

Monitoring Review and Ongoing Program Administration The Monitoring Review includes an onsite visit that

focuses on evaluation of a QE’s data security systems, and implementation of their policies and procedureso Other standards examined during the Monitoring Review are

determined from the Minimum Requirements Review Ongoing Program Administration is a means of providing

ongoing support to QEs throughout their tenure in the programo Includes submission and examination of Annual Reports

detailing QEs’ activities over the past year

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