2017 Merit-based Incentive Payment System Data Validation and Auditing

In previous columns, we have discussed the roadmap to Merit-based Incentive Payment System (MIPS) strategy and documentation. Your documentation may be subject to an audit so, you will need to provide information to verify your MIPS participation. This column will begin to discuss the data validation and audit criteria. In the next column, we will review a sample MIPS Audit Checklist. The following information is excerpted from https://qpp.cms.gov/about/resource-library (select hyperlink to MIPS Validation Criteria, April 26 zip file).

The Medicare Access and CHIP Reauthorization Act of 2015 streamlines a collection of programs with a single system where you can be rewarded for better care. You will be able to practice as usual, but you may receive higher Medicare payments based on performance. The 2 paths in this program are MIPS and Advanced Alternative Payment Models:

Under MIPS, 4 connected performance categories will affect your Medicare payments: Quality, Improvement Activities, Advancing Care Information, and Cost. This fact sheet provides a high-level overview of 3 of the MIPS performance categories for the transition year. Detailed criteria are included in an accompanying spreadsheet (https://qpp.cms.gov/about/resource-library/, MIPS Data Validation Criteria [zip file]). Note that criteria will be released incrementally according to the following schedule:

• Improvement Activities—Spring 2017
• Quality—Summer 2017
• Advancing Care Information—Summer 2017

The Quality Payment Program Final Rule with comment requires the Centers for Medicare & Medicaid Services (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.

Data validation is the process of ensuring that a program operates on accurate and useful data. The 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, the CMS will conduct an annual data validation process. You could receive a request from CMS for an audit, which requires an initial response within 10 business days.

Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.