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Challenges with Claims Based Reporting in Practice

On August 23, 2021, CMMI released changes to Primary Care First’s quality reporting which will require practices to use claims for reporting Advance Care Planning copying reporting used in the acute care program called the Bundled Payments for Care Improvement (BPCI) Initiative.

We’ve been advocating for and supporting the CMS Innovation Center Primary Care First program since it was announced. It’s exciting because it increases flexibility and payments to primary care practices to work beyond the patient visit and take on responsibility for an attributed patient population. Our PCF services includes quality monitoring, Qualified Registry submission, attribution support, practice coaching and program expertise.

We would like to share concerns about claims reporting and some of the challenges our clients have encountered.

For context, we have been helping practices monitor and submit quality measurements to CMS and other entities for nearly a decade. We are happy to work with clinicians, practices, and organizations to support the transition to value-based care by monitoring performance across more than 300 measures. We use several different sources of data to find out how you can maximize your performance.

Here are our top 6 concerns informed by our experience as a value-based care and qualified registry vendor supporting over 75,000 clinicians since 2012:

1. Claims reporting does not improve patient care.
  • Quality data codes add complexity to an already difficult and expensive process. Focusing on claims distracts providers and practices from patient care and may ultimately put quality reporting into the hands of coders instead of clinicians.
  • Administrative monitoring and follow up resources will be directed to coding efforts and not care improvement. Claims-based reporting highlights practices who are better at submitting claims but not necessarily better at providing services.
  • Quality data codes cannot be added to any previously submitted claims nor can they be amended if incorrect. If the claims process is not working at the beginning of the year, all eligible instances without the QDC code will NOT be counted as successful care regardless of the patient care.
  • BPCI or Bundled Payments for Care Improvement is not an ambulatory program designed for longitudinal care monitoring. It is inappropriate to apply the same quality metrics to very different care environments.
2. Monitoring performance is an important part of quality improvement efforts.
  • Claims reporting only reports quality for traditional Medicare patients and not the practice population.
  • Claims reporting is not a “best practice” in quality monitoring. In fact, CMS has been phasing out claims-based reporting and is currently limiting claims reporting to small practices. The decision to use claims reporting for an innovation program reverses the stated intent of CMS in quality reporting.
  • In the best-case scenario, CMS may provide feedback about practice performance quarterly. However, that tracking has yet to be developed and released. There may be many invisible steps between the visit and CMS recording performance
  • Custom reporting and monitoring are possible. Vendors will need to be vetted, implement their solution and teach practices to utilize the reporting. Practices end up paying for the support to be successful.
  • Clinical staff will struggle to see claims codes associated with different encounters and codes that are visible are often difficult to interpret. Monitoring and reporting on quality care requires visibility into what care has been delivered.
3. EMRs and Practice Management software are not designed to monitor claims measure performance.
  • Most electronic medical records or practice management software do not have the ability to calculate performance on individual measures.
  • Determining the eligible population, eligible claims and then Met/Not Met status will require, at least, a very complex report with algorithms to get any information.
4. The work of Registry Reporting is already underway for PCF sites.
  • All Cohort 1 practices were required to contract with Qualified Registries or QCDR organizations for PY 2021 and beyond.
  • All Mingle contracted clients have sent data for analysis. Processes for monitoring and data transfer have been established.
5. PCF participation should reduce administrative burden.
  • The reporting change increases the process development burden on all participants when they should be focused on practice improvements to care delivery.
  • The participant organizations have committed technical and professional resources throughout 2021 to build workflow and process reports to reflect the improvement work they are doing and support the quality improvement process. These resources will now be tasked with completing the registry work while also building a reliable claims-based process.
  • The time and effort to complete the contracting process was wasted for participants.
  • It is unclear if further changes to quality monitoring will be made in the coming practice years.
6. Claims reporting will not save money for practices in PCF.
  • Many practices do not submit CPT II or QDC to their billing clearinghouse because of the charges associated with each claim or claim line.
  • Claims reporting will increase billing costs to practices.
Share your perspective

In our work with clients to submit Measure 047 Advance Care Planning (ACP), only 1 PCF client has had any accurate QDC codes in their claims data. The ACP measure performance associated with claims data was <2% which is less than the quality gateway requirement.

If you or your practices share any of our concerns about this change, please reach out to the Primary Care First team at CMS CMMI to help them understand your perspective. You can reach them at: PCF at


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