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.
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.
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 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 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:
|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|
The measure can be scored based on performance.
The measure meets all of the following criteria:
Scenario 1 measures will be awarded 3 to 10 points based on performance compared with the benchmark.
1 bonus point is available for both:
|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:
|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:
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.