QE101: Introduction to the Qualified Entity (QE) Program

1. March 22, 2013 QE101: Introduction to the Qualified Entity (QE) Program

2. Today’s Objectives • Introduce QE Program and its mission • Introduce QECP and its activities • Describe QE requirements and their derivation • Describe methods for determining and ensuring compliance with requirements

3. QE Medicare Data Sharing Program: What it is? • 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.

4. 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

5. QE Medicare Data Sharing Program: Mission “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.”

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

7. 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.

8. 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

9. 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

10. 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

11. QECP Application Process 2012/2013

12. 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 procedures • 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 program • Includes submission and examination of Annual Reports detailing QEs’ activities over the past year