What is the Qualified Entity Program?

The CMS Qualified Entity (“QE”) Program has been in existence since 2012, making standardized extracts of Medicare claims data (Parts A, B, and D) available to “qualified entities” for purposes of engaging in the evaluation of healthcare provider and/or supplier performance.  Under the QE Program, Qualified Entities are required to combine Medicare data with data from multiple other claims sources and generate annual public reports using approved measures to evaluate performance.  Data are provided by geographic area based on the area(s) for which the QE has sufficient non-Medicare claims data to yield statistically reliable results when combined with Medicare data for the same geographic area(s).  There are currently 25 Qualified Entities certified by CMS.

Additional uses of Claims Data

In September 2016, CMS published a Final Rule modifying the QE Program to allow QEs to use Medicare claims data to conduct non-public analyses and provide or sell combined data and/or analyses, consistent with certain program requirements.  QEs must follow program requirements for public reporting on approved measures, but the authorization for these additional uses and analyses of Medicare claims data is a significant incentive to participation in the QE Program.

How to become a QE: The Qualified Entity Certification Program ("QECP")

The Qualified Entity Certification Program (“QECP”) consists of four phases of review:

  • Phase 1 – Review of the applicant’s organizational structure, ability to successfully carry out required QE activities, and access to additional claims data;
  • Phase 2 – Review of the entity’s compliance with program requirements for data security and privacy;
  • Phase 3 – Review of the entity’s compliance with additional requirements related to measure selection, public reporting, and the corrections and appeals process;
  • Phase 4/Public Reporting – Engaging providers in the corrections and appeals process and releasing public performance reports.

QEs are eligible to begin receiving Medicare claims data upon certification of Phase 2 compliance and submission/approval of the QE Data Use Agreement and CMS’ receipt of payment for the data.  The QE must complete Phase 4 within one year of its receipt of Medicare claims data and must continue to meet public reporting requirements annually thereafter. 

Taking on the QECP process requires a team of experts that bring specialized legal, information technology and security, claims, analytics, and other healthcare expertise to the table.  Familiarity with the certification process and timeline, submission requirements, and even the online application platform are significant advantages to successfully and efficiently navigating the QECP application process.  Similarly, having an understanding of what the QECP reviewers are looking for in an application and being able to effectively manage communications with CMS can be critical to staying on schedule and within budget. 

Nixon Law Group together with Nixon Health Nexus has the team and the experience to manage the QE application process for your organization. We were pleased to guide Clarify Health Solutions through the QECP process successfully; Clarify recently announced that it has become the 25th Qualified Entity certified since the program’s inception in January 2012.  If you would like to learn more about the Qualified Entity Program or would like additional information on how NLG/NHN can provide QECP process management, please contact us today.