May 1, 2019 | Cathy Thomas Hess, BSN, RN, CWCN

4 min read

Understanding Your Merit-based Incentive Payment System Performance Feedback Report

After taking the time to diligently document and report your Merit-based Incentive Payment System (MIPS) measures and activities, it is important to review your Performance Feedback Report detailing the category scores for your MIPS data submission. The scores provide you with payment adjustment information (excluding voluntary submitters) and details about measures and activities.

Clinicians participating in the MIPS or Advanced Alternative Payment Models (APMs) track of the Quality Payment Program may receive feedback on their performance to identify areas of excellence and improvement.

The following information details the MIPS information submitted in 2017 for the 2019 payment adjustment. Review the entire fact sheet and user guide for complete details.

Who Will Have MIPS Performance Feedback?

Individual clinicians (including voluntary submitters), groups, and MIPS APM entities (ie, those with MIPS-eligible clinicians scored under the APM scoring standard) will receive MIPS performance feedback. 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 will only receive MIPS performance feedback if they elected to participate in MIPS. Qualifying APM participants will not receive MIPS performance feedback.


What Is MIPS Performance Feedback?

At the end of the submission period, the Centers for Medicare & Medicaid Services started providing preliminary performance feedback to share scores in progress. These preliminary scores were subject to change as more data became available, such as:

  • Scoring updates based on a special status (eg, reweighing the Advancing Care Information [now known as Promoting Interoperability; this column will use Advancing Care Information because that is what will appear on clinicians’ feedback forms as stated within the Fact Sheet] performance category to 0% for hospital-based MIPS-eligible clinicians)
  • All-Cause Hospital Readmission measure calculations
  • Consumer Assessment of Healthcare Providers & Systems for MIPS Survey results
  • Advancing Care Information hardship exception application status
  • Improvement Study Participation and Results
  • Performance period benchmarks for quality measures that did not have a historic benchmark

Final MIPS performance feedback, available in July 2018, reflects special scoring circumstances and all the MIPS data submitted or calculated for an individual clinician, group, or APM entity. This final feedback includes the 2017 final score, 2019 payment adjustment information (excluding voluntary submitters), and details about measures and activities.



How Do I Access My MIPS Performance Feedback?

Individual clinicians, groups, Medicare Shared Savings Program Accountable Care Organizations (ACOs), and Next Generation ACOs, as well as their authorized representatives, can access performance feedback by logging into qpp.cms.gov with their HARP (Healthcare Quality Information System Access Roles and Profile)3 credentials (previously known as Enterprise Identity Data Management credentials) that allowed them to submit and view their data during the submission period.

  • Shared Savings Program ACOs will have access to final MIPS performance feedback at the APM entity (ACO primary TIN) level. Groups and solo practitioners participating in a Shared Savings Program ACO (ACO Participant TINs) will also be able to access the APM entity-level feedback by logging into qpp.cms.gov.
  • Next Generation ACOs will have access to MIPS final performance feedback at the APM entity (primary TIN) level only.
  • All other MIPS APM participants will receive their payment adjustment and performance feedback directly from their APM entity, not by logging into qpp.cms.gov.

With the exception of Shared Savings Program and Next Generation ACOs, APM entities with MIPS-eligible clinicians scored under the APM scoring standard will not be able to access their MIPS performance feedback by logging into qpp.cms.gov and therefore will not need to get HARP accounts to access performance feedback.

  • Final MIPS performance feedback will be distributed by the specific APM team to APM entities with at least one MIPS-eligible clinician scored under the APM scoring standard.

If you do not have a HARP account, start the process now to ensure you can access MIPS performance feedback in a timely manner, and if necessary submit a request for targeted review if you believe there are errors in your final score or payment adjustment.



To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.

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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.

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