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Insights19 CareOptimize Free Utilities

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Healthcare technology has so many moving parts, it’s often difficult and always a challenge to keep up. CareOptimize is continually developing solutions to help alleviate the pain. Please join Director of Development and Head of Strategic Initiatives Kyle Quirk for a look into three of our most popular, valuable, and FREE utilities: Clinical Operations Manager, Document Management/Care Guidelines Auto Complete, and the State of the Practice Report.


Managed Care: Success with Medicare Advantage

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CareOptimize works directly with CareMax Medical Centers, seven full-risk, full-service Medicare Advantage facilities in South Florida. All provide a full spectrum of medical services, including transportation (fleet of 50 vans) and home visits. Because these centers are full-risk, it is imperative CareOptimize monitor each center carefully to ensure CareMax centers remain successful value-based operations. To help do this, they have come up with a suite of templates for physicians and coders to work together at point-of-care not only to make the most beneficial coding decisions, but also to simplify the process.

Managing MA members in comparison to FFS
Medicare Advantage pays a capitated amount per beneficiary and focuses on proactive preventative care and early intervention. Care coordination and innovation are incentivized, and a risk adjustment model is used for patient differences. A comparison chart on cap rates per member per month illustrates how the MA contract rate fluctuates and how it might benefit practices.

Accurate HCC coding provides accurate RAF scores, and that accuracy reflects how well codes have been documented at point-of-care. Most CareMax members are joined with HealthSun, a large Medicare Advantage payer with a coveted 5-star rating from CMS. If HEDIS scores are managed well, HealthSun maintains their 5-star rating, which triggers a 5% bonus in addition to the base per patient per month payment.

By offering providers and payers accurate information, CareOptimize has been able to boost CareMax Medicare Advantage premiums. When Medicare Advantage is managed through accurate HCC coding, etc., even more funds can be generated.

To maximize our systems and take advantage of the Medicare Advantage model, we created a system at point-of-care for physicians to ascertain exactly what they need for accurate coding. This system tracks HCC drop-offs and suspected and overdue codes. The coding review process between provider and coder was streamlined, so coding opportunities would be caught before claim creation. We wanted to back all of this up with aligned workflows in the EHR, so we designed templates to do just that.

The pre-audit process lets providers know there is a set number of patients for the next day. A pre-audit review is generated, which includes suggested codes by coders based on holistic evidence. The physician can see and review the information at point-of-care, including codes, diagnosis descriptions, and status of patient (new or not) in their daily assessments. They can accept the code as is if they feel it’s valid or choose no evidence of disease right there, and go on with their notes. Simplifying the coding process benefits both provider and payer, giving crucial information at point-of-care to be generated, allowing for much more accurate results.

MIPS – What’s New, What Isn’t, and What You Need to Know Now

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The MIPS program continues, with all of its trials and triumphs. While many of the parts of the program remain the same, there are some key pieces to keep in mind, so you won’t be left behind in the pursuit of a positive attestation. If you haven’t started on MIPS for 2018, there is still a possibility for reporting and meeting the minimum threshold for the reporting year, especially if you have less than 15 clinicians. It is also important to remember if you haven’t actively engaged in MIPS program and are always waiting to hit that neutral adjustment, scores are publicly available on the Physician Compare website for all to see.

The official attestation period for the 2018 reporting year began on January 2, 2019, and the deadline to send everything in is April 2, 2019. For groups submitting their practitioners as individuals (vs. group), consent does have to be given. A Practice Administrator may give consent on behalf of a group or virtual group, but not for a MIPS-eligible clinician reporting as an individual. MIPS data needs to include all payers for QCDR/Registry/EHR submissions. Medicare only applies exclusively to the Claims and Web interface submissions. The completeness of data must include all payers. For group submissions, data across the entire TIN, including data from non-Eligible Clinicians, must be included.

For 2018 the threshold for data completeness is 60%. Since it is supposed to be an accurate representation of data, you cannot select only the best performing patients. CMS has provided a lot of clarification about this in the last couple of months.


2018 is the first year practices are being graded on their cost performance. Although this information was provided in 2017, it wasn’t included as part of the overall score. In 2018, there are two measures: TPCC (Total Per Capita Cost – attribution plurality of primary care svcs – specialty-only groups will have patients who fall into this category) and MSPB (Medicare Spending Per Beneficiary – plurality of Part B services billed). Groups where the Eligible Clinician is not attributed any Cost measures will not be calculated a Cost performance score. In 2019, there will be eight new episode-based measures added.

Keep Good Records

It is very important for all to keep good documentation records, and CareOptimize highly recommends having an audit binder. CMS can audit practices up to 6 years after the program year in which you attested, so for PY 2017, you could be audited to 2023. Documentation that should be included in your audit binder includes proof from the registry stating your data was successfully submitted to CMS and a copy of your Security Risk Assessment report that was completed or reviewed, along with the date of completion. The same SRA report can be used and updated year to year. CMS has provided clear breakdowns per measure on what should be included in your audit binder on their website:

For 2018, you do need to be on a 2014 or 2015 certified EHR. If you are looking at an upgrade, such as moving from a 2014 to a 2015 certification, you do need to keep documentation supporting the time period in which you are attesting in your audit binder.

For all measures submitted in the Quality/PI categories, we highly recommend storing that year’s measure details in your audit binder as well as documented workflow used. Include screenshots within the EHR. It doesn’t have to be for specific patients, but you do need to be able to show how the providers are capturing the info. For PI measures, an ONC certified EHR is required to complete the report, which should be included, with numerator and denominator calculations, vendor logo, and timeframe in which you are attesting.

For additional measures within PI reporting, specifically specialized registry reporting and public health measures, it is critical to have documentation from state agencies including emails, screenshots, or receipts showing active engagement.

The CEHRT Bonus in Improvement Activities is a yes/no measure, and you need to include screenshots of the activity being completed for your attestation time period.

What 2019 looks like

The 2019 MIPS period has now started. MIPS 2019 includes two 12-month segments. The timeframe currently posted on the CMS website is October 1, 2017 to September 30, 2018. The second timeframe will be October 1, 2018 to September 30, 2019. Some changes:

  • Quality category now makes up 45%, a lower rate than it previously had, and Cost is 15%.
  • Exceptional performance threshold is now 75 points.
  • CMS is sticking with their decision to have a 2015 CEHRT requirement, which must be in place at least one day during the reporting period.

We can learn a lot from previous years. CMS reported that 93% of MIPS Eligible Clinicians received a positive payment adjustment and 95% avoided a negative adjustment. They have been quite good at predicting trends for the future. For 2018, they predict only 74% of clinicians would earn a score higher than 70% qualifying for the exceptional performance threshold.

Minimum points are increasing from 3 to 15. Distribution of points is also different with the Cost category being implemented and Quality having a smaller percentage. The same trend is expected to continue in 2019, with a minimum point increase to 30 points.

There is an increase in Eligible Clinicians for 2019. The threshold is the same (>$90,000 billed to Medicare, >200 services to Medicare beneficiaries, and > 200 covered professional services), but if you meet one, but not all conditions, you can still opt in for 2019. (Keep in mind once you have opted in, you can’t change it for the applicable performance period.) This will help increase the number of organizations participating and working toward attestation and the possibility of potential positive adjustment.

If you are actively working on 2018 MIPS submission, you should still be looking toward 2019, since there are areas needing work now that will affect your scores down the line. Right now, you should be:

  • Actively reviewing measures (not all will be available for 2019 – make sure to note which will and will not)
  • If you’re working toward that 75-point threshold for 2019 reporting year, education and retraining are extremely important.
  • Understand changes coming and who might benefit, with the additions of new clinicians that can come in as well as the opt-out.
  • Plan your upgrade if you are not already on a 2015 CEHRT.
  • Implement and train on risk adjustment coding. This is where clinicians can actively engage in Cost category to help impact it by simply accurately documenting chronic conditions, which can greatly help improve performance.

Ensuring you keep good records, staying up-to-date on CMS guidelines (, and getting the help you need will all help you reach you attestation goals. For more information, please contact CareOptimize at, call 855-937-8475, or visit our website

Insights: MIPS 2019 Proposed Rule & Preparation

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CMS has released the proposed rule for MIPS in 2019. Hear from Jonathan Shivers on the potential impacts to your practice and how to best prepare for the increased bonus payment opportunities. During this complimentary webinar we will cover updates on:

• Eligibility Requirements
• Performance Categories and Weights
• Thresholds for Performance
• Payment Adjustments and More

Quality Manager

By | Blog

The CareOptimize Quality Manager is a one stop shop for all items quality related.  We combine all quality, regulatory and incentive programs into one user friendly dashboard.  We will build your Quality Manager specific for your practice and measures.  The Manager will allow you to view programs, measures, patients and encounter dates.  The functionality will also allow you to search a specific patient if desired.

Other features of our Quality Manager include single sign on for certain EHR users.  Single breakdowns by measure, provider or patient. Our module is SSL encrypted for your security.  Real time tracking of your programs so you can easily navigate the road to meeting your practice’s goals.  Care gaps are identified immediately so they can quickly be addressed. With bi-directional integration we can automatically send codes via the Manager to your EHR.  Our Quality Manager is accessible from anywhere.

Our Quality Manager not only allows your user to see an overview of different Quality programs such as MIPS, HEDIS, eCQM measures, it will also allow the user the ability to further explorer specific measures.  Drilling down into the measures will show clinicians any patient gaps that need to be worked and where they need to continue to improve as they continue to provide your patients excellent medical care.



MIPS Mid-Year Update : Insights Recap MIPS 2018 Mid Year Update

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Our insights presentation focused on the mid-year updates for MIPS 2018.  CMS has released 2017 final scores. You can find your score, by logging into to and using your Enterprise Identity Management (EIDM) account.  EHR and Registry entities will not have access to the final scores.  As a reminder 2017 performance adjustments will be applied in 2019.
2018 MIPS changes include changes to the definition of Eligible Clinicians.  Also, we will see changes in the minimum thresholds that have to be met by all EC’s to qualify for MIPS.  This year the Quality category will be weighted at 50% of the final scores.  While Promoting Interoperability, formerly ACI will account for 25%.  Improvement Activities will remain at 15%.  We have the addition of the cost category and it will account for 10% of your final score.  Minimum submissions increased 3 points to 15.  We will also see changes in bonus points.  These include Improvement bonus, 2015 Edition Bonus, and End to End reporting bonus.
At the mid-year point of 2018, your focus should be first on continued tracking of performances measures.  Staying ahead of performances will help ensure your practice succeeds in 2018 MIPS. If you submitted for 2017, downloading and reviewing your final scores will give you a base to decide if your current measures are the most beneficial.


Insights: Quality Manager Overview

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We’ve just crossed the mid-year mark. If you haven’t been focused on closing your patients’ 2018 quality gaps, now is the time.

When working on your gap list, it is imperative to compare your findings to your health plans’ findings. CareOptimize’s Quality Manager makes this easy by identifying discrepancies and providing a workflow for resolving them. You’ll also see:
– How to work gaps at the point of care.
– Submitting gap closures to the health plan with just one click.
– A brief peek at our predictive coding tool.