Provider Data Management   /   April 2017

MACRA’s Quality Payment Program: What to Expect

MACRA’s Quality Payment Program: What to Expect

Medicare is forging ahead with a payment program that links physician pay to measured quality of care. “This could be the beginning of baseball-style score cards for physicians,” says Dr. Garry Choy, radiologist and chief compliance officer at CredSimple. “Instead of tracking RBIs and home runs, physician reports cards will track patient outcomes.”

The idea of quantifying physician effectiveness isn’t brand new to healthcare, but it has been getting increased attention because of the legislative changes to The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in October 2016. The key changes to MACRA include the Quality Payment Program (QPP) which, according to CMS is designed to “improve Medicare by helping [providers] focus on care quality and the one thing that matters most — making patients healthier.”

While QPP raises many questions for providers and healthcare organizations, one of the most pressing questions is simply: How? How will we track physician quality so we can ensure they are paid in a fair and timely manner?

We predict health plans will need to prioritize these five areas:

  • Start with an adequate network of high-quality providers. A thorough and compliant credentialing process will help ensure your network is comprised of providers focused on improving patient outcomes.
  • Stay on top of sanctions. Real-time sanctions alerts allow you to take charge of your network so you have the power to decide how to strategically handle any sanctions that arise.
  • Establish an infrastructure for tracking physician practice patterns and quality-of-care metrics. Monitoring for patterns allows health plans to better identify areas for improvement and helps a plan encourage providers to practice in a way that optimizes health outcomes and quality.
  • Better tracking of delineation of privileges. Doing so allows you to track professional competencies under Clinical Practice Improvement Activities (CPIA), a contributor to overall score and MACRA measurements.  By tracking what providers do clinically, one is also tracking the evidence that supports what privileges providers should be credentialed for.
  • Data readiness. The accuracy of a health plan’s data and how that data is structured has become increasingly important, partly due to how it affects reporting. Downstream processes and business intelligence are helped or hindered by underlying data, and the urgency for accurate data that is structured in a useful way only increases as more and more reporting is required as a result of MACRA and other recent regulations.

Healthcare organizations run on data. With MACRA and QPP, the importance of understanding the quality of your network, and then monitoring providers for sanctions, licensure and malpractice changes only increases. This is where the credentialing process comes in.

The birthplace of provider data is credentialing: when a provider joins a network, it starts a provider file that contains key data points on that provider.  For years, this data has been siloed in the credentialing department and it sat inert, collecting dust until the next credentialing cycle.

With increased pressures for efficiency — not only on the provider end, but on the business strategy and administration end as well — it is obvious that the provider data created during credentialing is too valuable to be left alone.

The bottom line: data matters. How and where you collect and store data matters. It matters to quality-of-care reform, industry regulations, business strategy and provider relations.


It’s your choice: Your credentialing process can either merely check the compliance box or can launch you ahead of the curve on data accuracy, provider relations, compliance and network management. Learn more about how CredSimple can help. Choose a demo time that works for you.


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