June 30, 2022 | Jessica Zeff

3 Minute Read

‘Tis the MIPS Audit Season…And This is Your Guide to Survival!

The MIPS audit season is upon us and those of you who submit MIPS data through a Qualified Clinical Data Registry (QCDR) will be beset by requests for audit documentation.  Never fear, this is all part of the MIPS QCDR process and is mandated by CMS.  Ok, ok, I hear you groaning; I get it: audits are not fun and we all have other things we’d rather be doing.  But there’s no real way out so the best we can do is come up with a bit of a survival guide to make the whole process a little less daunting.

Planning Is the Key to Survival

Those of us who have worked in healthcare know that the best audit outcomes depend on good planning.  Good planning greases the, so called, audit wheel and makes the audit process easier to navigate. And nowhere is this truer than in the wonderful, wacky world of MIPS where compliance audits are routine rather than the exception.  As many of you will already know, effective planning takes a lot of time, effort, and resource. Contrary to popular belief, though, planning doesn’t have to be painful. (I know, heresy, right?) This is particularly the case when planning for MIPS success, that is, understanding MIPS measures and how to demonstrate compliance with those requirements. 

Much Ado About Planning

Now, some of you may be rolling your eyes at me here and wondering what I’m going on about.  I mean, what’s all this fuss about planning?  Successful MIPS participation is simply dependent on detailed and accurate clinical documentation, right?  Wrong.  We all wish it was that simple!  In fact, MIPS success starts long before documentation comes into the picture. It starts with planning and truly understanding your MIPS measures.  (Although good documentation is certainly a “must.”)

There is no such thing as too much planning!

By planning, I don’t mean a project management plan on a spreadsheet.  Planning for MIPS success is about:

  • Taking steps to identify each measure you intend to report and looking to the detailed measure specifications on CMS’ Quality Payment Program (QPP) website https://qpp.cms.gov/mips/explore-measures.
  • Checking the type of measure being reported, i.e., whether it’s an outcome measure or a process measure.
  • Confirming the collection type, of which there are six:
  • Electronic Clinical Quality Measures (eCQM)
  • MIPS Clinical Quality Measure (CQM)
  • Qualified Clinical Data Registry (QCDR) measure
  • Medicare Part B claims measures
  • CMS Web Interface measures
  • Understanding the measure specifications and reading the numerator and denominator definitions.
  • Knowing the data to collect for your chosen measures, i.e., age, BMI, initial assessment, medical history, claims forms, codes, medication review. (I’m thinking of everyone’s favorite bug bear: medication.)
  • Reviewing documentation templates to ensure there is a place for capturing relevant information.
  • Ensuring those who are collecting patient information know what information to collect and document.
  • Having internal audit or quality assurance processes to check that the information required by the measure specifications is being collected.
  • Routinely check your QCDR performance data to make sure data is flowing from your EHR to your QCDR.  If you spot a problem, talk to us about it!

Plan the Plan

All that said, I’d hate to rob our beloved spreadsheet of a role to play!  I’d say the use of some tool (like the humble spreadsheet) to plan and manage your MIPS documentation, audit, and data submission is essential.  “Yes, we know that” you say, “so what’s your point?” My point is that your plan should be comprehensive and include the whole range of MIPS related activities that are relevant to your organization.  This includes identifying key milestones, QCDR requests for documentation, data submission dates, required resources, and any conflicts with other regulatory or business activities.  Use the spreadsheet to identify a timeline, establish milestones, assign responsibilities, allocate resources, and monitor progress.  Use it to help you determine where you need additional resources, IT support, and admin capability in order to meet milestone deadlines.

Don’t forget your QCDR!

For those of you who partner with QCDRs, it’s imperative that you understand how that relationship works and plan accordingly.  There are tremendous benefits to working with a QCDR, not the least of which is helping you to submit accurate data to CMS. Those benefits depend on a timely submission to your QCDR of a sample of patient records for audit and review, if they are requested.  No doubt you have many demands for copies of patient records and a request for patients records from your QCDR might seem like another spin on the bureaucratic merry-go-round. Having a plan, in advance, for responding to your QCDR may take some of the sting out of the request.  Timely submission of the right records will allow your QCDR to conduct mandated audits that will help you get the most out of MIPS.  Remember, QCDRs have no choice in whether to conduct an audit of your patient records.  They are required to do so by CMS.  Equally important, though, having a plan for organizing and submitting records for audit may take some of the strain off you and your staff, and allow you to do what you do best: provide care and treatment to your patients! 

Helpful Planning Tips

I’m not saying that the planning steps I’ve outlined above are easy to adopt. They’re not, especially for smaller practices.  Some ideas, though, that have been shared with me and which might make the planning process easier include:

  • Involving key staff in teeing up documentation templates and developing discrete data fields and prompts and alerts to help therapists complete the documentation. 
  • For some measures, these staff may be able to collect and document data directly with therapist oversight and review.
  • For group practices, perhaps different therapists could agree to champion particular measures that will be collected for all therapists in the practice.

Final Words (for now)

There’s no doubt that surviving a MIPS audit requires time, energy, and focus that might otherwise be spent on patient care.  At least, that’s one way of looking at the cost of the effort.  I would agree that the planning requires effort but I would argue that planning is an investment that has the potential for significant future dividends.  The dividends are in MIPS success:  positive reimbursement adjustments; higher quality healthcare; evidence-based treatment; and increased patient engagement.

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