Quality Reporting FAQs

Frequently Asked Questions (FAQ)

1. Does my practice need to do quality reporting?

The following physicians are required to perform quality reporting:

  • PCP and Specialty physicians who are part of MSHP’s Clinically Integrated Network
  • PCPs who have signed a Care Management Payment Addendum and receive Care Coordination Fees for their attributed members

2. How often must I perform quality reporting and how do I determine which patients to report on? Do I report only on my patients covered by Mount Sinai Health Partners payer agreements?

For 2019, quality reporting is due quarterly for PCPs and biannually for specialists. See below for the deadlines:

  • The deadline for Q4 2019 quality reporting is January 17, 2020*
    For Q4 2019, begin reviewing charts for quality measures with the last patient seen on November 15, 2019.
  • The deadline for Q3 2019 quality reporting is October 11, 2019
    For Q3 2019, begin reviewing charts for quality measures with the last patient seen on August 16, 2019.
  • The deadline for Q2 2019 quality reporting is July 12, 2019*
    For Q2 2019, begin reviewing charts for quality measures with the last patient seen on May 17, 2019.
  • The deadline for Q1 2019 quality reporting is April 19, 2019
    For Q1 2019, begin reviewing charts for quality measures with the last patient seen on March 8, 2019.

*Specialists will be reporting on a biannual basis in July and January through Box.com.

For each quarter, working backward sequentially from the target date, review each patient seen and document performance for each measure per patient.
Please note that you are not specifically reporting on your MSHP patients. Quality reporting is payer-agnostic.

3. How many patients must I report on?

For each quality reporting metric, practices must report on 10 patients per quarter per measure. For each specialty, there are 5-8 metrics.

4. What tool will I use for quality reporting?

  • MSHP has developed a quality reporting tool using an Excel templated form that will be sent to your practice.
  • In order to use the quality reporting tool, practices must have Excel 2007 or a more current version of Excel. Older versions of Excel or Excel 2010 versions that have not been updated since purchase (e.g. Windows and Microsoft software updates) may not have optimal functionality or be able to open the reporting file.
  • Practices must have a PC-based operating system. Macintosh systems will not support the template functionality.

5. Where can I find more information on the metrics for my specialty?

You can access a complete listing of measures and descriptions by specialty on the Mount Sinai Health Partners website here.

6. I am both a specialist and a primary care physician. Which specialty do I use to report?

If you are a PCP receiving care coordination fee from MSHP for your attributed members and you want to continue to receive these payments, then please use the reporting tool for your PCP specialty (e.g., pediatrics, adult primary care, geriatrics). If not, please use the specialist reporting tool.

7. Can I report as a PCP in Q1 & Q2 and then change and report as a specialist in Q3 & Q4?

No. Please choose which specialty you are reporting under and remain consistent in your quality reporting.

8. Will MSHP change its metrics over time?

Quality reporting metrics will be evaluated on an annual basis by the MSHP Board of Managers and set for each calendar year. These metrics may be subject to change. Notification will be sent out identifying such changes for calendar year 2017 and beyond.

9. Is my patient data secure?

Yes. Reporting tools, measure descriptions and guides are shared using Box, the Mount Sinai Health System Enterprise Cloud-based File Sharing Portal. Box is HIPAA-certified and an industry gold-standard for secure file sharing.

Box will be used for:

  • Receiving (downloading) files from Mount Sinai Health Partners
  • Sending (uploading) completed reporting tools to Mount Sinai Health Partners

The person in your practice responsible for quality reporting will be given access to Box and receive an email invitation (Note: if you did not receive the email invitation, please check your “junk” or “spam” folders). If that person wishes to share his or her access to the Box folders with other people in the practice, he or she may select “Invite People” after signing in and enter the email of the person who needs access.

10. Will MSHP be reporting my quality data to CMS or other regulatory bodies?

No. The collection of 2016 performance data is for the sole purpose of establishing baseline norms and gaining insight into how best to optimize the data collection process.

11. How will my quality performance be measured?

In the Fall, practices will receive a Quality Metrics Dashboard. Practices will receive dashboard results per measure, benchmarking their scores against colleagues in their practice as well as their colleagues in the MSHP network.

12. Do all physicians in my practice need to sign the Quality Reporting Attestation Form?

Yes. All physicians whose patient data is reported must sign the form, attesting to completeness and accuracy of data.

13. What do “numerator” and “denominator” mean?

Physician quality reporting measures consist of two major components. The first measure component is the denominator, which describes the eligible cases for a measure or the eligible patient population. The second component is the numerator describing the specific clinical action required by the measure for performance. Calculating the reporting rate (dividing the numerator by the denominator) identifies the percentage of a defined patient population that was reported for the measure. For performance rate calculations, some patients may be excluded from the denominator based on medical, patient or system exclusions allowed by the measure.

Source: Adapted from: https://questions.cms.gov/faq.php?id=5005&faqId=3247

14. My patient refused treatment/diagnostics. Can I document that in the quality reporting tool?

In the event a patient did not receive the appropriate measure-specific treatment, diagnostics, intervention, etc., practices may indicate a reason (medical exception or patient refusal).

Note: A documented medical exception or patient refusal will count in the numerator for that measure only if it is an acceptable exclusion. Please refer to the measure description to determine the acceptable exclusions. That exception must be clearly documented in a visit note.

15. My office has an Electronic Medical Record (EMR) system. Do I still need to use the Excel-based quality reporting tool or can I report my data another way?

If your practice is operating on an EMR, and that EMR captures discreet data values that allow queries to be written to determine if patients meet numerator and denominator criteria AND you have the practice resources needed to write queries to generate feeds, it is possible that MSHP can accept a data feed from your practice. Please contact your Provider Engagement Manager or call MSHP at 877-234-6667 to discuss this further.

16. Does each physician in my practice need to fill out a separate reporting tool?

No. If multiple physicians practice in the same specialty, the practice can fill out one reporting tool for that specialty. When you are finished reporting for one physician and ready to move on to reporting for the next physician, please be sure to click on the blue button on the form that says “Set Practice Physician” and fill out the accompanying fields for the physician whose data you are reporting.

17. How should I name the file I return to Mount Sinai Health Partners?

Please do not change the filenames of the reporting templates that are placed in your Box.com account by MSHP.