The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) streamlines a patchwork collection of programs with a single system where you can be rewarded for better care. You’ll be able to practice as you always have, but you may receive higher Medicare payments based on your performance. There are two paths in this program:
- Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
Under MIPS, there are four connected performance categories that will affect your Medicare payments: Quality, Improvement Activities, Advancing Care Information and Cost.
This fact sheet provides a high-level overview of three of the MIPS performance categories for the transition year. Detailed criteria is included in an accompanying spreadsheet. Note that criteria will be released incrementally according to the following schedule:
- Improvement Activities – Spring 2017
- Quality – Summer 2017
- Advancing Care Information – Summer 2017
MIPS Data Validation and Auditing
The Quality Payment Program Final Rule with comment requires CMS to provide the criteria we will use to audit and validate measures and activities for the transition year of MIPS for the Quality, Advancing Care Information and Improvement Activities performance categories.
By definition, data validation is the process of ensuring that a program operates on accurate and useful data. MIPS requires all-payer data for all data submission mechanisms with the exception of claims and the CMS Web Interface. The data from payers, other than Medicare, will be used for informational purposes to improve future validation efforts and will not be the only source of data used to make final determinations on whether you pass or fail an audit in the transition year.
Under MIPS, CMS will conduct an annual data validation process. Additionally, you could receive a request from CMS for an audit, which requires an initial response within 10 business days.
What’s the requirement if I use a third party to submit my MIPS data?
For the transition year, third party intermediaries such as Qualified Clinical Data Registries (QCDRs), Health IT Vendors, Qualified Registries, or CMS-approved CAHPS for MIPS Survey Vendors are required to comply with several procedures as a condition of their qualification and approval to participate in MIPS as a third party intermediary including: providing the contact information for you and all individual clinicians or groups on behalf of whom it submits data. Also, entities must provide your phone number, address, and, if available, your email.
How long should I retain documentation?
In accordance with the False Claims Act, you are encouraged to keep documentation up to 10 years and, as stated in the final rule, CMS may request any records or data retained for the purposes of MIPS for up to 6 years.
The Quality performance category within MIPS assesses health process and outcomes through quality measures.
MIPS eligible clinicians should demonstrate improved quality above a baseline level, known as the performance benchmark. The performance benchmark is based on historical or performance period data (or potentially based on 2017 performance data for quality measures with no historic benchmark).
For the transition year, CMS’ data validation process for the Quality performance category will apply for claims and registry submissions to validate whether you submitted all applicable measures when submitting fewer than six measures or when you do not submit the required outcome measure or other high priority measure, or submit less than the full set of measures in the applicable specialty set.
Advancing Care Information
The MIPS Advancing Care Information performance category replaces the Medicare EHR Incentive Program for eligible professionals, also known as Meaningful Use. The MIPS Advancing Care Information performance category promotes patient engagement and the electronic exchange of information using certified EHR technology. Under this performance category, eligible clinicians will have greater flexibility in choosing measures to report.
You should retain documentation to support their submission for the Advancing Care Information performance category.
The MIPS Improvement Activities performance category assesses how much you participate in activities that make clinical practice better. Examples include:
- Activities related to ongoing care coordination
- Clinician and patient shared decision making
- Regular use of patient safety practices
- Expanding practice access
Under this performance category, you’ll be able to choose from many activities to show your performance. This performance category also includes incentives to help you participate in certified patient-centered medical homes and APMs.
Your documentation used to validate your activities should demonstrate consistent and meaningful engagement within the period for which you attested.
For the transition year of MIPS, the Cost performance category is not assessed.
The Quality Payment Program Service Center can be reached at 1-866-288-8292 (TTY 1-877-715- 6222), Monday through Friday, 8:00 AM-8:00 PM Eastern Time or via email at [email protected].
Download the MIPS Data Validation Criteria