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Back to the blogApr 7, 2020

NCQA PCMH, HEDIS, & CMS QPP Policy Changes for COVID-19

NCQA PCMH, HEDIS, & CMS QPP Policy Changes for COVID-19

The current COVID-19 pandemic has overshadowed any other medical issue for weeks and will continue to do so in the coming months. Obviously, the coronavirus crisis has placed incredible pressure on all aspects of the medical system. Providers are struggling to care for those sick with the virus as well as their regular patients. Their businesses are suffering while they are sacrificing their own health to take care of patients. Fortunately, government agencies recognize that "business as usual" is not an option, so both the NCQA and CMS have altered their regulatory policies to ease bureaucratic burdens on medical personnel and facilities. Due to the COVID-19 pandemic, NCQA has updated both PCMH & HEDIS programs while CMS has updated its QPP & Medicare Advantage policies.

NCQA HEDIS & PCMH Requirement Changes for COVID-19

The National Committee for Quality Assurance (NCQA) has announced changes to its regular procedures due to the current healthcare situation, including the HEDIS &  PCMH programs, due to COVID-19. NCQA's mission is, as always, to enhance patient care by promoting best practices in the healthcare industry. Because providers are so overtaxed, they recognize that further changes may be necessary and are looking to the CDC and other healthcare authorities for guidance in this area. They have already made several necessary alterations.

National Committee for Quality Assurance (NCQA) Announcements

NCQA has announced the following changes due to COVID-19:

  • It will virtually conduct their business activities when necessary.

  • It is currently assessing how to make large meetings, conferences, and other events virtual.

  • It will continue its usual business, such as surveys, support services, contract services, and grant-related services

The goal is to protect the safety of all personnel while still fulfilling its mission to safeguard the public interest.

NCQA HEDIS and CAHPS Reporting

Since the focus must currently be on the COVID-19 outbreak, NCQA is flexible about 2019 HEDIS reporting requirements. The emphasis is also on employee safety, so they have offered the following modifications to their procedures:

  • NCQA has aligned with CMS requirements, and will not require Medicare Advantage plans to submit their data for accreditation purposes.

  • Accredited commercial and Medicaid plans will proceed with annual reporting requirements for NCQA HEDIS and CAHPS. NCQA is expecting that the data will not calculate an appropriate overall plan rating, so they will not use Health Plan Ratings for accreditation scoring in 2020.

  • It is understood that other exceptions may occur, so NCQA has adapted their disaster protocols and will work with organizations needing any further accommodations.

  • NCQA HEDIS auditors will be emphasizing remote site visits and the use of online reviews, virtual technology, faxes, and regular mail due to COVID-19.

  • 2021 Medicare Part C and D Star Ratings now eliminate the collection of 2020 NCQA HEDIS and CAHPS data. Earlier 2020 values will be replaced to calculate the 2021 Star Ratings.

Mandatory NCQA HEDIS Reporting

Of course, some states have their own reporting requirements, and NCQA can only make recommendations in those instances. NCQA advises states with mandatory HEDIS reporting requirements to allow HEDIS 2019 rates for plans with low chart retrieval rates. NCQA is facilitating this adjustment by recommending it to each state's Medicaid system.

NCQA PCMH Accreditation and Recognition

To alleviate some accreditation and recognition reporting burdens during the current health crisis, NCQA has enacted exceptions for Patient Centered Medical Homes (PCMH) during the March 1-September 1 timeframe to ease the burden during the COVID-19 pandemic. 

These accreditation and recognition exceptions include the following:

  • Practitioners that are out of network and providing care to members/patients as part of federal, state, or local emergency response do not need to be credentialed. Disaster management plans that were executed during this timeframe must be documented that details how these providers cared for patients.

  • NCQA will waive requirements that organizations verify out of state provider licenses when credentialing those providers that are temporarily practicing out-of-state.

  • NCQA will score an NA if a requirement conflicts with federal or state emergency response regulations; however, the organization must provide evidence of this regulatory conflict.

  • NCQA will provide flexibility in scoring performance during the March 1-September 1 timeframe, and documentation needs to be included regarding any conflict to meet requirements.

  • For those accreditation activities where barriers to timeliness occur, NCQA is extending the grace period 2 months which now allows 16 months for annual requirements, removing files from March-September.

Additional NCQA Changes

In the near future, NCQA will make public some additional guidance for Medicare and commercial health plans that report for the Health Insurance Exchange Quality Ratings system. Providers should stay alert for new announcements from that system and other government agencies. Not surprisingly, the situation is quite fluid and requires frequent adjustments.

CMS 2021 Medicare Advantage and Part D Rate Announcement

On April 7, 2020, CMS released the 2021 Medicare Advantage and Part D rate announcements after reviewing the comments from the Advanced Notice's earlier this year. The grid below shows the percentage rate changes for the 2021 Rate Announcement.

2021 Rate Announcement Impact

  • Effective Growth Rate: 4.07%

  • Rebasing/Re-pricing: -0.35%

  • Change in Star Ratings: 0.23%

  • MA Coding Pattern Adjustment: 0%

  • Risk Model Revision: 0.25%

  • Encounter Data Transition: 0%

  • Normalization: -2.54%

  • Expected Average Change: 1.66%  

CMS Alters MIPS/QPP Policy

CMS policies have changed because of COVID-19 to ease the strain on the nation's healthcare system. Depending on the severity and length of the current crisis, they may take further steps to make it easier for providers to stay in compliance. CMS administration has already invoked an important emergency policy to aid providers.

MIPS Extreme and Uncontrollable Circumstances Policy

In response to the COVID-19 pandemic, CMS has applied the MIPS Extreme and Uncontrollable Circumstances Policy, which relaxes reporting procedures for providers without imposing penalties for missing previously set deadlines. These important changes include the following;

  • An extension of the 2019 Merit-based Incentive Payment System (MIPS) data submission deadline until April 30, 2020.

  • An automatic inclusion in the extension program for clinicians. Any MIPS eligible clinician who does not submit their required information by April 30 will be automatically included in the program and will ultimately receive a neutral payment adjustment for 2021. You can check your status through the QPP Participation Status Tool.

  • They are reopening the MIPS Extreme and Uncontrollable Circumstances policy for individuals, groups, and virtual groups. Those who should submit an application include individual clinicians with submissions they already started but are unable to complete, groups that are unable to complete applications they already started, and virtual groups that cannot begin or finish their reporting. Applications submitted between April 3 and April 30, 2020 that cite COVID-19 will override any previous submission of required data.

Your staff members may find it challenging to keep up with all the policy changes. To address this issue, the CMS encourages providers to consult CMS.gov for more information. You may call 1-866-288-8292, M -F, from 8:00 am to 8:00 pm EDT. You can also email QPP@cms.hhs.gov

The TempDev Advantage

No healthcare organization can effectively navigate this crisis alone. You will need to draw on all available resources to provide excellent patient care and protect your physicians, nurses, and other staff members.

The TempDev team can advise you on appropriate provider solutions during this time of crisis and help relieve some of the pressure it is causing. Our expert regulatory consultants are staying current with the constantly changing advice from various government agencies, including NCQA, CMS, and the CDC. Many providers are overwhelmed by the influx of coronavirus patients, and the bureaucracy that treating them brings. 

TempDev, working closely with industry leader NextGen Healthcare, can advise you on software solutions that will ease your burdens and the burdens of your staff. We can also provide vital staff augmentation that will relieve pressure on your current employees. If you need technical support or training, our team can offer you prompt assistance.

We stand ready to help in any way we can. Contact TempDev today to discuss your provider management options.


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