MIPS – Important Items to do In December
December 21, 2018
written by Sharon Phelps
2018 only has a few days left, are you prepared to report MIPS?
It may seem like an overwhelming task, but it doesn’t need to be. To help make the reporting process less difficult, we created a list of things to do to ensure you are on track for MIPS 2018 submission.
- Ensure you have access into the QPP portal. This secure portal gives you access to your 2017 performance results, your 2018 eligibility at both the group and individual level, any 2018 claims data you may have submitted (remember this is only a partial look at your claims) and it is where you can both enter and view data submitted for 2018.
**Two recently updated/added items:
- CMS has now incorporated the eligibility results from the second determination period (9/1/2017 – 8/31/2018). Check your list of clinicians to see if the eligibility status for any of your clinicians has changed. https://qpp.cms.gov/participation-lookup
- The preview period for Physician Compare has opened. This preview period allows you to view the 2017 Quality Payment Program performance data before it is posted on Physician Compare in early 2019. The data will be available for preview until January 7, 2019.
- If you are reporting in the Promoting Interoperability category, ensure you have completed your Security Risk Assessment and have a plan for addressing the vulnerabilities and threats found in the assessment.
- If you are claiming an exemption in the Promoting Interoperability category, ensure you complete the exemption forms no later than 12/31/18.
- Clinics are reporting they have been audited on data submitted for 2017 MIPS, so it is important to gather your data now while you are interacting with it. You’ll be prepared in case you get audited in 2018.
- CMS has a helpful document on the Resources pageregarding what documentation should be kept and helpful hints in case of an audit. The name of this file is “2018 MIPS Data Validation Criteria” and it downloads in a zip file. In this zip file, there are PDFs on Improvement Activities Changes and Criteria, Promoting Interoperability Changes and Criteria and Quality Measures Criteria.
- A few helpful hints for your audit folks:
- Create a binder that has all the supporting documentation for your Improvement Activities, your Security Risk Assessment (SRA) and actions related to the findings, and any other supporting documents pertaining to MIPS you would need in case of an audit.
- Make sure whoever is doing your MIPS reporting for you isn’t the only person who knows where that binder is and what it contains.
- Create a naming convention to use every year, to make it consistent and intuitive to everyone in your clinic.
- Reporting via Claims? Have you checked on the QPP portal for preliminary claims submission details?
- Reporting via Registry? Have you engaged with the registry you are using to know the and understand the expectations?
- Reporting via EHR? Have you confirmed with your EHR vendor the steps that need to be taken to obtain a QRDA formatted report to upload to the QPP portal? Have you discussed (and understand) the responsibilities of your EHR vendor versus your responsibilities as a clinic?
One last item – CMS will be removing access to the PQRS feedback reports and Quality and Resource Utilization Reports (QRUR) from the Value Modifier program as of 12/31/18. While this is old data (2016 and previous), it may provide your clinic with historical data regarding cost that you may not otherwise access. You can download these reports in case you’d like them for reference in the future.
Again, if you have any questions, contact us at firstname.lastname@example.org or use the “Leave a Reply” section below, and one of our subject matter experts will get back to you.