March 11, 2021 | Jessica Zeff

3 Minute Read

Planning for Your MIPS QCDR Random Audit

Don’t be pulled, lead!!

Have you ever felt like you were being pulled in all different directions at once by different people needing you?  I imagine that’s what healthcare providers often feel like when they’re asked to provide copies of patient records. There are patients, clinicians, insurance companies, and auditors all wanting copies of patient records.  The volume of requests may feel like a deluge!

Quality Clinical Data Reporting (QCDR) vendors, such as FOTO, are obligated to randomly audit a percentage of providers that report their data through our QCDR for MIPS.  Providers are expected to submit patient records to enable FOTO to audit for errors related to the quality data submitted.  If FOTO identifies any errors, providers have an opportunity to correct the errors before FOTO submits the quality performance data to the Centers for Medicare and Medicaid Services (CMS) so that the providers can get their MIPS incentive funding. Submission of data to CMS runs from January – March.

This audit work is vital to the financial health of so many of our providers so careful planning and dedicated resources for ensuring FOTO receives needed patient records is paramount.  It is important that FOTO receives the specific patient documentation that allows us to audit appropriately against specific MIPS measures and that FOTO receives the information in the timeframes requested.  This helps us give our providers the best chance of success with MIPS.

That said, FOTO recognizes that the demand for sharing patient records with such a multitude of requesters may be overwhelming.  The best way for providers to cope with these requests is to develop processes which allow for more control over the requests and better ensure positive outcomes. Below, are a series of steps that may help providers to do just this.

Step 1

Start by cataloging the volume and types of requestors and the typical turn-around times required to respond to patient record requests.  Review the types of requestors and common timeframes and the typical volumes of records requested.  Do you and other staff understand why these requests are repeated? Is it to support different quality or performance or risk adjustments that are intended to translate into additional payment? Is the requestor an auditor that has the ability to deny or take back payment?  Check insurance and auditor requests to determine if there is a pattern of denials and on what basis from any of these requestors.

Step 2

Check there are sufficient staff and resources to support the effort. Just on shear volume alone, are there enough staff to deal with the number of requests?  This is an important initial assessment.  Also, are you able to leverage the EHR portal for patients requests for records?  What can be done to reduce patient requests for records?  Consider whether your EHR supports automatic patient care activity to consulting, primary care and other clinicians. This should reduce the burden on staff to copy and submit/send records.

Step 3

Look at the process for receiving requests. Do staff know the most critical types of requests that may come in? What if a letter was received by the U.S. Department of Justice or the Department of Health and Human Services Office of Inspector General?  These are requests you would want to know about as soon as possible and ensure any deadlines are met. 

Step 4

Put in place a process to meet requests from contractors working with companies that validate quality and risk data. Deadlines here are important because missing them could cause a clinician to miss out on risk adjustments, performance bonus (for example, MIPS) or other types of payment based on reporting.

In Summary

Successful MIPS reporting relies on patient records audits and the timely provision of the patient records needed for those audits.  And while FOTO can’t avoid asking our providers for patient records, we can take the sting out of the requests.  We do this by 1) ensuring careful and considered communication with our clients; 2) asking only for the number of records we are required to audit; 3) requiring only the sections of patient records which allow us to carry out our audits (as opposed to full patient records); 4) accepting electronic patient records.  Providers can help the process run even more smoothly through proactive consideration and implementation of the steps outlined above.

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