Quality Payment Program

Mona Mathews, MA, PMP

Chris Becker, CPHIMS, CPHIT

Lori Manteufel, BBA

Health Care Quality Symposium

November 14, 2018

1

Disclaimer

Content provided in this presentation is based on the

latest information made available by the Centers for

Medicare & Medicaid Services (CMS) and is subject

to change.

CMS policies change, so we encourage you to

review specific statutes and regulations that may

apply to you for interpretation and updates.

2

Objectives

1.Understand the Quality Payment Program

(QPP)

2.Learn how others communicated the QPP to

physicians and staff

3.Understand changes in 2018 QPP

4.Learn how to estimate your Merit-based

Incentive Payment System (MIPS) score to

help you set improvement goals

5.Review the 2019 QPP proposed rule

3

Introductions

4

Lake Superior Quality Innovation Network

Lake Superior Quality Innovation Network

(Lake Superior QIN) is comprised of three quality

improvement organizations:

• Stratis Health in Minnesota

• MetaStar in Wisconsin

• MPRO in Michigan

5

MetaStar is a member of the Quality Payment Program Resource

Center® for the Midwest, a Centers for Medicare & Medicaid Services-

funded collaboration among 10 key partners across Michigan, Ohio,

Indiana, Illinois, Kentucky, Wisconsin and Minnesota, focused on

supporting providers in small practices, and rural or underserved areas.

Our Resource Center® provides free help to eligible clinicians as they

navigate participation in the Quality Payment Program.

6

2017 Reporting and Performance Feedback

7

2017 Reporting Observations

Most practices experienced a smooth reporting process

Challenges

• Obtaining Enterprise Identity Management

(EIDM) service account

• No submit button

• Uploading quality data

8

Lessons Learned from 2017 Reporting

• Obtain an EIDM account early and make sure you

can log in

• Work with your vendor to make sure you have the

proper files to upload to the reporting portal

• There is no submit button

• You can report multiple times for groups and

individuals

9

Performance Feedback

Immediate feedback was given during the reporting

period

• This feedback changed during the reporting

period

• Feedback was only an estimate

• Did not reflect any special scoring, hardship

application status or Improvement Study

Participation and Results

Official feedback results became available on

July 1, 2018

10

Which Clinicians will have MIPS Performance Feedback

• Individual clinicians (including voluntary submitters),

groups, and MIPS Alternative Payment Model

(APM) Entities

• Clinicians who practice in multiple groups, as

identified by a Taxpayer Identification Number

(TIN), will have performance feedback for each

group under which they participated in MIPS

• Partial Qualifying APM Participants (Partial QPs)

will only receive MIPS performance Feedback if

they elected to participate in MIPS

11

Group Discussion

12

Questions

What was your experience with 2017 reporting?

• Reporting portal

• Problems with reporting

• Resources you utilized

How did you share feedback reports with clinicians and staff?

What factors influenced you when it came to sharing

feedback information?

Did any of you file a targeted review and if you did what was

your experience with the process? If yes, what was the

result?

13

2018 Program Overview

14

MIPS Eligible Clinicians (EC)

*Physicians: Doctors of medicine, osteopathy, dental surgery, dental

medicine, podiatric medicine, or optometry, and chiropractors*

*With respect to certain specified treatment, a Doctor of Chiropractic legally authorized to practice

by a state in which he/she performs this function

Physicians* Nurse

Practitioners

Physician

Assistants

Clinical

Nurse

Specialists

Certified

Registered

Nurse

Anesthetists

No change in the TYPES of clinicians eligible to participate in 2018

15

2018 Year 2 MIPS Eligible Clinicians

2017 Year 1

• Bill > $30,000 Medicare Part B AND

• Provide care to > 100 beneficiaries

2018 Year 2

• Bill > $90,000 to Medicare Part B AND

• Provide care to > 200 beneficiaries

Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible

clinicians billing more than $90,000 a year in Medicare Part B allowed charges

AND providing care for more than 200 Medicare patients a year.

*Voluntary reporting remains an option for clinicians exempt from MIPS

16

No Change in Basic MIPS Exemption Criteria

1. First year enrolled in Medicare

2. Significantly Participating in an Advanced APM

• 25 percent of Medicare payments paid through Advanced APM

• 20 percent of Medicare beneficiaries seen through Advanced APM

3. Low Volume Threshold

• Exempt if either < $90,000 billed OR < 200 visits during

determination period (in either of two prior billing years)

• Determined at TIN/National Provider Identifier (NPI)) for

individuals, AND

• At the group TIN for groups

17

QPP Eligibility Look Up Results

MIPS

Participation

Status Tool

Source: https://qpp.cms.gov/participation-lookup

18

2018 Reporting Options

Clinicians participating as a group are assessed as a

group across all four MIPS performance categories.

The same is true for clinicians participating as a

Virtual Group.

Source: CMS-QPP-Year-2-Final-Rule-National Provider Call-Slides.2017.11.30

19

Two Paths for QPP: MIPS and APMs

Path One: APMs

Advanced APMs and MIPS APMs

20

Path One: Advanced APMs

Alternative Payment ModelsNew models of paying for health care that incentivize quality and value over

volume by moving away from traditional Medicare Part B Physician Fee Service.

Advanced APMs

Subset of APMs that receive a 5 percent bonus payments if ECs meet

thresholds to become Qualified Professionals

Three statutory requirements:1. Participants must use certified electronic health record (EHR) technology

2. Payment for covered services based on quality measures comparable to MIPS

3. Entity is either 1)

―a Medical Home Model expanded under CMS Innovation Center authority OR

―Requires participants to bear more than a nominal amount of financial risk

21

APM

Advanced

APMs

APM

MIPS APM

MIPS

What are MIPS APMs?

Middle ground between reporting to MIPS categories and being a full-fledged

Advanced APM

Examples:

• ECs in Advanced APMs who don’t meet thresholds for Advanced APM

• Medicare Shared Savings Program (MSSP) Track 1 (Upside risk, no downside risk)

MIPS Eligible CliniciansQualified

Participants

MIPS Eligible

Clinicians

Source: https://qpp.cms.gov/

22

Two Paths for QPP:

Path Two: MIPS

23

Path Two: MIPS

Previous

Category –

Year

Physician Quality

Reporting System

(PQRS)

New CategoryEHR Incentive

Program

Value Based

Modifier (VBM)

2018 50 % 15 % 25 % 10 %

2017 60 % 15% 25% 0 %Source: CMS Quality Payment Program – Train-the-Trainer

Quality Improvement

ActivitiesPromoting

Interoperability Cost

Four MIPS category scores compiled for

MIPS final score worth up to 100 points

24

MIPS: Quality Category

25

Quality Category: 50 percent of MIPS Score in 2018

Earn up to 60 Quality Category points

• Scored on the highest six quality measures from 277 measures

― May pick from specialty set

― Must include at least one outcome or high priority measure

• Earn three to 10 category points for measures with benchmarks

• Earn up to seven points for six measures - if “topped out*” two or more years*

― Must meet data completeness criteria (2018 increased to 60 percent)

• 2018 Earn one point for reporting if data completeness not met

― Small practices still earn three points

• Bonus points for reporting end to end electronically (electronic clinical quality

measure (eCQM))

• Bonus points for reporting additional outcome or high priority measures

*Topped out measures have little room for improvement

26

Quality Category: 50 percent of MIPS Score in 2018

New: Scoring Improvement Bonus

worth up to 10 percentage points • Based on improvements in total category score

• Higher improvement results in more points

MIPS Reporting methods

1. Claims, EHR, Registry, Qualified Clinical Data Registry (QCDR) -60 category points

• Each reporting method has different benchmarks

2. CMS Web Interface 110 - 140 category points

• Only for groups of 25 plus

• Must report on 14 quality measures

• APMs report collectively as an entity (all TINs)

27

2018 Specialty Measure Sets

1. Allergy/Immunology2. Anesthesiology 3. Cardiology 4. Dentistry5. Dermatology 6. Diagnostic Radiology7. EPT Cardiology 8. Emergency Medicine9. Gastroenterology 10.General Oncology 11.General/Family Practice 12.General surgery 13.Hospitalist 14. Infectious Disease 15. Internal Medicine 16. Interventional Radiology 17.Mental/Behavioral Health18.Nephrology

19.Neurology20.Neurosurgical21.Obstetrics/Gynecology22.Ophthalmology23.Orthopedic Surgery24.Otolaryngology25.Pathology26.Pediatrics27.Physical Medicine28.Plastic Surgery29.Podiatry 30.Preventive Medicine 31.Radiation Oncology32.Rheumatology 33.Thoracic Surgery34.Urology 35.Vascular Surgery

28

MIPS Quality Measures

https://qpp.cms.gov/mips/quality-measures

29

MIPS Quality Benchmarks

To score more than three points:1. Benchmark

2. Minimum case size of 20

3. Data completeness

• Claims: >50 percent of Part B claims

• QCDR, Registry, EHR: > 50 percent

of all payers

• CMS WI: First 243 claims

Measur

e ID

Measure_N

ame

Reportin

g

Method

Measur

e Type

Benc

h

mark

High

Priority

Topped

Out Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9

Decile_

10

112

Breast

Cancer

Screening Claims Process Y N Yes

38.46 -

48.01

48.02 -

55.67

55.68 -

62.78

62.79 -

69.41

69.42 -

77.18

77.19 -

87.87

87.88 -

98.52

>=

98.53

112

Breast

Cancer

Screening EHR Process Y N Yes

12.41 -

22.21

22.22 -

32.30

32.31 -

40.86

40.87 -

47.91

47.92 -

55.25

55.26 -

63.06

63.07 -

73.22

>=

73.23

112

Breast

Cancer

Screening Registry Process Y N Yes

14.49 -

24.52

24.53 -

35.70

35.71 -

46.01

46.02 -

55.06

55.07 -

63.67

63.68 -

74.06

74.07 -

87.92

>=

87.93

ACO-20

Breast

Cancer

Screening

CMS

Web

Interface Process Y N Yes 30 40 50 60 70 80 90 100

30

MIPS: Cost category

31

Cost: 10 percent of MIPS Score in 2018

Category Performance Score included in composite MIPS score starting in 2018

TWO measure scores are averaged (or any one available)

1.Medicare Spending per Beneficiary (MSPB)

2.Total per capita cost measures

• Category score weight will increase to 30 percent by 2021

• No data submission required; Calculated from administrative claims if meet case minimum of attributed patients

• Benchmark calculated using current year performance

• New: Scoring Improvement Bonus up to one percentage point

― Based on statistically significant changes at the measure level

32

MIPS: Improvement Activities (IA) Category

33

Improvement Activities: 15 percent of MIPS Score 2017-2018

Maximum Category score 40 points

• Help participants prepare to transition to APMs and Medical Home Models. Additional activities available in 2018, some changed

• Engage in up to four activities for at least 90 days

― Medium activity = 10 points

― High activity = 20 points

• Earn Promoting Interoperability (PI) category Bonus points for using CEHRT for some IA

• Report by simple Yes/No attestation

Special Scoring:• Full credit (40 points): clinicians in patient-centered medical home (PCMH),

MSSP, Next Generation APM

• Half credit (20 points): clinicians in other APMs

• Double points: clinicians in small underserved or rural settings, and non-patient facing clinicians/groups

34

MIPS Improvement Activities

*Many others available

35

Path Two: MIPS

Promoting Interoperability(PI) category

36

Promoting Interoperability: 25 percent of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

Earn up to 25 MIPS points

2018: May use either 2014 or 2015 Certified EHR Technology (CEHRT) (or combination)

• 10 percent bonus for using only 2015 CERHT

• Base measures, required for any score in this category

― Earn 50 points

― Four base measures for 2014 CEHRT, five for 2015 CEHRT; some measures also earn performance scores

― Exclusions available for two base measures: e-Prescribing and Health Information Exchange: Send Summary of Care

• Performance measures Optional

― Earn up to 90 points

― Seven for 2014 CEHRT, nine for 2015 CEHRT

37

Promoting Interoperability: 25 percent of MIPS Score

Bonus points

Earn up to 25 percent in 2018 ― Use 2015 Certified EHR Technology exclusively – 10 percent

― Use CEHRT for at least one Improvement Activity (IA) – 10 percent

― Report to one public health (PH) or clinical registry - 10 percent

― Report to any additional PH or clinical registry – 5 percent

38

Automatic Reweighting of Promoting Interoperability

PI category is automatically reweighted to quality when: (unless EC reports data to IA category)

1. MIPS EC types: nurse practitioner (NP), clinical nurse specialists (CNS),

certified registered nurse anesthetist (CRNA), physician assistant (PA)

2. Some “Special Status” MIPS ECs:

• Non-patient facing: ≤100 Medicare B patient-encounters

• Hospital-based: >75 percent encounters in hospital setting

― inpatient, on-campus outpatient hospital or emergency department

(ED); Point of Service (POS) 21-23

3. Groups with > 75 percent of clinicians meeting Special Status

39

Application for Reweighting of Promoting Interoperability

PI is NOT automatically reweighted to quality for these types of MIPS ECs

• EC must apply for hardship exception

1. Clinicians in small practices

2. EHR decertified - retroactive to 2017

3. Significant hardship exception

― Five year limit removed

4. CMS designated natural disasters (Federal Emergency Management Agency (FEMA))

Applications for reweighting must be submitted by December 31, 2018

40

2014 vs 2015 Certified EHR

Four Base Measures = 50 points

Seven Performance Measures

• Earn up to 10 points each

• Two worth 20 points each

Five Base Measures = 50 points

Nine Performance Measures

• Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base)

Provide Patient Access (Base)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View, Download, or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base)

Request/Accept Summary of Care (Base)

Provide Patient Access (Base)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View, Download, or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses,

but maximum category score is 100

41

MIPS Scoring and Reporting

42

Performance Period 2017 - 2018

Promoting

Interoperability Promoting

Interoperability

Source: CMS Quality Payment Program – Train-The-Trainer

43

Virtual Groups

• Solo practitioners and groups of 10 or less EC come

together virtually to participate in MIPS as a group

• Election process must occur before beginning of

performance period

―Election period October 11 - December 31, 2017

for 2018 performance period

• No changes after performance period starts

44

MIPS 2018 Year 2Scoring (0-100 Points)

≥70 points Eligible for positive payment adjustment and exceptional

performance bonus payment

15.99 – 69.99 points Positive payment adjustment. No exceptional performance

bonus payment. No negative payment adjustment

15 points Neutral payment adjustment

3.76 – 14.99 points Negative payment adjustment ranges from -4.9 percent to - 0.1

percent

0 - 3.75 points -5 percent payment adjustment.

Increase in performance threshold and payment adjustment

Source: Stratis Health MIPS Estimator, https://www.mipsestimator.org

45

New Bonuses in 2018

Bonus eligibility: Must report on at least one MIPS category

Bonus added to final MIPS Score

1. Complex Patient Bonus

Up to five bonus points for treating complex patients. Score based on

• Hierarchical Condition Category (HCC) risk score +

• Percentage of dual eligible beneficiaries

2. Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

46

Scoring Examples

47

Scenario One

Background• Solo Practice Surgeon

• Eligible Clinician (exceeds low volume threshold)

• Must report to avoid a negative penalty

• Does not utilize an EHR

Reporting Options• Needs to obtain 15 MIPS Points to remain Neutral

• Could attest to Improvement Activities

• Report Quality Category via claims or registry

• Note: Practices with 15 or less clinicians get some special scoring

48

Solo Surgeon Reporting with No EHR

• Clinician decides that she does not want to pay for a

registry and go through the trouble of doing chart

reviews to populate the registry

• Finds out that billers have been submitting some “G”

Codes for Medication Reconciliation and Body Mass

Index Screening but they did not meet the 60 percent

data completeness for quality

• Attests to using the Prescription Drug Monitoring

Program (PDMP)

49

Score for this Solo Clinician

One

Improvement

Activity

Two Quality

Measures

Five free

points for

being a small

practice

Small Practices receive double points for Improvement Activities and a

minimum of three points for quality measures Source: Stratis Health MIPS Estimator

https://www.mipsestimator.org/

50

Scenario Two

Background

• Group Practice with 16 Eligible Clinician Types

• Has EHR through the local hospital

• Two of the clinicians exceed the low Volume Threshold

• The remaining 14 are eligible at the group level but not

individually

Reporting Options

• Group Reporting

• Individual Reports (two mandatory and 14 voluntary)

51

Scores for Mandatory Clinicians

Patricia WhiteWilliam White

Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/

52

Group Score

Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/

53

Group versus Individual Reports

Individual Report – The individual clinicians will

receive a payment adjustment

Group report – All eligible clinician types in the group

will receive a payment adjustment

In this example, the group score was greater than

either of the mandatory reporters so if a group report

was submitted, they would receive the higher of the

two scores.

54

Important Information About the Scenarios

Did not give any points for cost or complex patient

bonus

The scores were calculated based on the most

current benchmarks (some benchmarks will be

recalculated during the performance year)

55

Steps to Success in the Quality Payment Program

56

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path:

• APM (group) or

• MIPS (individual or group)

Collect data:

• Promoting Interoperability

• Quality measures

• Improvement activities

57

EIDM Account Set Up

To login and submit data, clinicians will use their Enterprise Identity Management (EIDM) credentials.

• The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems.

• The system will connect each user with their practice Taxpayer Identification Number (TIN). Once connected, clinicians will be able to report data for the practice as a group, or for individual clinicians within the practice.

• To learn about how to create an EIDM account, see this user guide.

• Quick Start Guide

58

Clinicians: Steps to Success in the QPP - continued

Review current performance

• Foster performance improvement

• Choose reporting periods for PI and IA

― 90 - 365 days

― Full calendar year for quality reporting

• Evaluate available reporting methods

• Choose group or individual performance

59

2019 Quality Payment Rule

60

2019 Rule Overview

• Rule was released on November 1, 2018 via the

Medicare Physician Fee Schedule (PFS)

• MIPS is continuing to ramp up

• New eligible clinician types

• Potential incentives and penalties increase

61

What is Not Changing

Timeline

• Performance period: January – December 2019

• Reporting period – March 2020

• Payment adjustment, begins January 1, 2021

Performance Period

• Quality and Cost: 12 months

• Improvement Activities and Promoting Interoperability 90 days

Types of exemptions

• Newly enrolled in Medicare

• Below low-volume threshold

• Significantly participating in Advanced APMs

62

MIPS Performance Period 2019

Source: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-MIPS-quick-start-guide.pdf

63

Key Changes

• Category weights change slightly – increase in cost and

decrease in quality

• Newly eligible clinician types

• Increase in performance thresholds, incentives and penalties

• Limiting the use of claims-based measures

• CEHRT Requirements – must use 2015 certification

• Third criterion for determining the MIPS Eligibility

• Opt in option for clinicians that meet at least one low volume

criteria

64

Category Weighting for 2019

Quality – 45 percent

• Data Completeness remains at 60 percent

• Claims Submission only for small practices

(15 or fewer clinicians)

Cost – 15 percent

Improvement Activities – 15 percent

Promoting Interoperability – 25 percent

• Must use 2016 CHERT

65

Eligible Clinician Types

Physical and

Occupational

Therapists

Qualified

Speech-

Language

Pathologists

Qualified

Audiologists

Clinical

Psychologists

Registered

Dieticians and

Nutrition

Professionals

Physicians Nurse

Practitioners

Physician

Assistants

Clinical

Nurse

Specialists

Certified

Registered

Nurse

Anesthetists

Year 1 and 2 Eligible Clinicians

2019 Newly Eligible Clinicians

66

Performance Threshold and Payment Adjustment

• Must obtain a minimum of 30 MIPS points to remain

neutral

• Exceptional bonus requires 75 MIPS points

• Maximum negative payment adjustment is 7 percent

• Performance in 2019 will affect Medicare payments

in 2021

67

Low-Volume Threshold Criteria

Source: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-MIPS-quick-start-guide.pdf

68

Small Practices

• Definition – 15 or fewer clinicians under the same TIN

• Increase the small practice bonus to six points, but include it

in the Quality performance category score

― Must report quality measures

― Bonus points subject to category weighting

• Continue to award small practices three points for submitting

quality measures that do not meet the data completeness

requirements

• Can continue to submit quality measures through Medicare

Part B Claims

• Option to participate as a virtual group

69

Audits: Are you Ready?

70

Historical Perspective

• Audits do happen

• Meaningful Use (MU) participants had an approximate one in

10 chance of being audited

• Auditors did retract incentive funds on behalf of CMS when

program participants failed the audit.

• Number one audit flag and reason for payment retraction:

― poorly done or no Security Risk Assessment for the

Protect Patient Health Information objective

• Biggest risk: not being prepared for an audit

• Prior MU program required two week response time to audit

materials request

71

Historical Perspective

• Six year retention period required for MU

attestation documentation

• Audits under MU were performed by a

contracted company (Figliozzi & Co.)

• Following two slides are excerpts from CMS

guidance document on MU audit program

72

Historical Perspective

73

Historical Perspective

74

The Basics of Audit Readiness

• Audits are in the news and have our attention

• June 12, 2017 article in ‘Fierce Healthcare’ online:

”Audit estimates CMS issued hundreds of millions

of dollars worth of incorrect EHR incentives”

• Detailed Office of Inspector General (OIG) PDF at:https://oig.hhs.gov/oas/reports/region5/51400047.pdf

75

Main Points in OIG Report

“On the basis of our sample results, we estimated that

CMS inappropriately paid $729,424,395 in incentive

payments to EPs who did not meet meaningful use

requirements. These errors occurred because sampled

EPs [Eligible Providers] did not maintain support

for their attestations. Furthermore, CMS conducted

minimal documentation reviews of self-attestations,

leaving the EHR program vulnerable to abuse and

misuse of Federal funds”

76

OIG recommends that CMS…

• Review eligible professionals (EP) incentive payments to determine which

EPs did not meet meaningful use measures for each applicable program

year to attempt recovery of the $729,424,395 in estimated inappropriate

incentive payments,

• Review a random sample of EPs’ documentation supporting their self-

attestations to identify inappropriate incentive payments that may have been

made after the audit period,

• Educate EPs on proper documentation requirements,

• Finally, as CMS implements MACRA, we recommend that any modifications

to the EHR meaningful use requirements include stronger program

integrity safeguards that allow for more consistent verification of the

reporting of required measures so that CMS can ensure that EPs are using

EHR technology consistent with CMS’s goal of Advancing Care Information

under MIPS.

77

The Basics of Audit Readiness

• Additional call by two senators on July 12 for follow

up on improper $730M payments

(Letter to CMS Administrator from Senators Hatch

and Grassley)

“If CMS is capable of recovering taxpayer money

that should have not have been spent, the agency

should take all reasonable steps to do so,” the

Senators wrote.

Source: Healthcare IT News: http://tinyurl.com/y8st79c2

78

Senators Foreshadow MIPS Auditing

79

Which Categories MIPS May Be Audited

CMS has

supplied

‘Data

Validation’

Excel tool

for IA

No CMS

guidance as

of yet.

Relying on

previous MU

information

No CMS

guidance as

of yet.

Relying on

PQRS and

MU previous

information

80

CMS Data Validation & Audit Fact Sheet

• CMS has provided a Data Validation and Audit Fact

Sheethttps://qpp.cms.gov/docs/QPP_MIPS_Data_Validation_Criteria.zip

• CMS requires a six year retention period for MIPS and

Federal False Claims Act encourages up to 10 years

81

CMS Data Validation and Audit Fact Sheet

• The Data Validation and Audit Fact Sheet is only three

pages and does not provide detailed guidance

• At the bottom of page 1, CMS states:

“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.”

• CMS will ‘validate’ the data your submit and may

also conduct an audit. Two separate and distinct

activities

82

Audit Readiness Excel Tool

83

Audit Readiness Excel Tool

84

Your Audit Readiness Files

• Best approach is an electronic set of files/folder for

quick response to CMS

• Prior submissions to the CMS contracted auditor

were done primarily via secure web portal (uploads)

• Organize at the TIN level as that is how the program

is organized and audit info will be requested

• Base your electronic folder structure on how you are

attesting (by individual provider or by a group) and

break down further into MIPS reporting categories.

• Create a year by year file structure

85

Questions?

Mona Mathews, Project Specialist

Chris Becker, Project Specialist

Lori Manteufel, Project Specialist

qpp@metastar.com

www.lsqin.org

www.metastar.com

This material was prepared by the Lake Superior

Quality Innovation Network, under contract with

the Centers for Medicare & Medicaid Services

(CMS), an agency of the U.S. Department of

Health and Human Services. The materials do

not necessarily reflect CMS policy.

11SOW-WI-A1-18-47 110718