Final 2021 MIPS Submission Report Overview

Your final 2021 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 2021 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 2021 MIPS performance year. 

To finalize your 2021 MIPS submission, review the final 2021 Group and Individual MIPS submission data published within the Keet Outcomes Dashboard. Once complete, submit the 2021 MIPS Submission Attestation Form to certify your reporting type and intent for Keet Health to submit your MIPS data to CMS.

Note

The information in the MIPS submission dashboard may vary from what is in the Keet Outcomes Dashboard v3.1. This is due to how the exclusion populations are applied in the final submission. The final submission data will be the data in the MIPS Submission Dashboard. Please utilize the MIPS Submission Dashboard for final data review and reporting selections.

Report Components & Definitions 

Submission Summary Report

Use the Submission Summary report to assess performance for MIPS submission.

Please note: only the providers who have consented to individual submission will be included in the individual sections of this report.

Total measures for each TIN/Practitioner that outperform the Keet Avg RA FTP

outperform_Keet_avg.png

Displays the number of MIPS measures where the TIN's/practictioner's Risk-Adjusted Average FTP rate was lower (positive performance) than the Keet Avg RA FTP rate. Additional columns indicate if the Keet Avg RA FTP rate was outperformed by 0-4.9%, 5-10%, or >10%.

Submission List & Submission List Detail Overview
Displays final submission populations at the Reporting Type level. If Reporting Type is set to Group, you will see the aggregate data for each measure under each TIN you have for submission. If Reporting Type is set to Individual, you will see the individual performance by measure per NPI for each practitioner that has provided consent to participate. The Submission List Detail provides additional information about the cases that make up each measure's population for the "group" reporting type.
Submission List
In the Submission List table, there are the populations you are used to seeing in the Keet Outcomes Dashboard as well as additional columns added to help you assess measure performance. These will help you determine what measures are outperforming the Keet average, and by how much. While the Keet average is not interchangeable with the CMS-generated benchmark, it will help you assess how your organization performed in comparison to the average keet client. As a reminder, the case minimum must be met, indicated by a blue Y before performance can be assessed. Measures that fail to meet the case minimum will receive data completeness points (3pts) only.
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Performance Met/Performance Not Met Populations
The Keet Outcomes QCDR measures are Inverse measures. As defined by CMS, "in an inverse measure- a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control." See the table below for how this translates to the familiar Keet Outcomes Dashboard terms.
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Submission Dashboard Name KOD Name Meaning
Performance_Met FTP Population Cases that did not meet or exceed the MCID.
Performance_Not_Met Progressed Population Cases that met or exceeded the MCID.
Submission List Detail - Contains EOCs for the ' ' reporting type
The submission list detail table includes the individual cases that are part of one or more reporting populations for the CMS quality measures. While individual patient-level detail is not submitted to CMS, this is included for you to be able to view the patients in each aggregate population. In addition to the recognizable column fields, we have added a column "included in submission" to indicate whether that EOC was included in the final performance rate submission calculation or is part of the exclusion or exception criteria. You may use the control "EOCs included in submission" to surface only those that are part of the final submission performance rate, or those that are removed. Note that when viewing submission list detail with the "GROUP" Reporting Type control selected, all providers will be listed as NULL as providers are not identified in GROUP level submission.
submission_list_detail_group.png

Submission Summary All Strata Report

In the final submission, Keet Outcomes QCDR provides multiple groupings of your quality performance data to CMS. CMS uses the risk-adjusted overall strata for final scoring as surfaced in the submission summary tab. Additionally, Keet has provided you all submission strata for optional review. This is displayed under the submission summary, all strata report. Here you will see a similar table with the measure specification populations for each of the 6 CMS-reported Strata. A Strata is a grouping of patients according to particular CMS-defined criteria. 

Each measure is represented by an observed and risk-adjusted population that population is then grouped or stratified by Treatment: 

Strata Treatment Definition
Observed NonOp MCID The proportion of [conservative] patients not achieving an MCID.
Observed Operative MCID The proportion of [surgical] patients not achieving an MCID.
Observed Not Achieving Overall proportion of patients not achieving an MCID.
Risk-Adjusted NonOpRisk A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported.
Risk-Adjusted OpRisk A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported.
Risk-Adjusted Overall A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported.

 

2021 Final MIPS Submission Data Review FAQs

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. Note that for 2021, if you have not met the case minimum on 6 out of 10 measures, you may be at risk of a negative payment adjustment. 

For additional information on scoring, refer to the QPP Traditional MIPS Scoring Guide. 

Scenario by Measure Description Scoring Rules Per Measure
1

The measure can be scored based on performance.

The measure meets all of the following criteria:
(1) Has a benchmark;
(2) Has at least 20 cases; and
(3) Meets the 70% data completeness requirement

Scenario 1 measures will be awarded 3 to 10 points based on performance compared with the benchmark. 

1 bonus point is available for both:

  • Using an outcome measure
  • End-to-end electronic reporting
2 The measure does not meet the 70% data completeness requirement.

Scenario 2 measures will be awarded 0 points, except for small practices, which will receive 3 points.

1 bonus point is available for:

  • End-to-end electronic reporting
3 The measure meets the 70% data completeness requirement but does not have at least 20 cases.

Scenario 3 measures will be awarded 3 points.

1 bonus point is available for:

  • End-to-end electronic reporting

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

No, Medicare will calculate the benchmark for 2021 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:

  • IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
  • IA_BE_7: Participation in a QCDR, that promotes use of patient engagement tools
  • IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive
  • IA_BE_22: Improved Practices that Engage Patients Pre-Visit

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 2021 MIPS Scoring Guide.