MIPS Submissions: 5 Tips for a Smoother Submission Process

For those of us who have any interactions with the Merit-Based Incentive Program (MIPS), January to March is a particularly busy time of year.  Some of us are still working through 2021 documentation audits, checking calculations, collaborating with clinical data registries, and generally working towards making our 2021 MIPS submissions to CMS.  At the same time, we’re already submitting data for the 2022 MIPS data collection, applying lessons learned from last year, and planning our MIPS audit strategies for this year.  This effort entails understanding changes to the MIPS program and related measures, that is, topped out measures, measures that have changed or been removed, and working with partners to make sure accurate data collection processes are in place. 

Whoa, that’s quite a lot to cram into such a short period of time!  And I know we’re all up for this annual challenge and will breathe a collective (albeit short) sigh of relief on March 31^st when 2021 MIPS submissions are finalized but a few words of wisdom (five tips, to be exact) to consider between now and then to (maybe) make the submission process easier:

Understand the MIPS Measures

Let’s face it, MIPS isn’t for the faint hearted and those of us who have invested part or the entirety of our careers in MIPS deserve a round of applause.  And understanding individual MIPS measures isn’t always that straightforward, it’s true, which makes it all the more important to dedicate time and resource to understanding them.  Easier said than done, I know.  Good resources that may help (and this isn’t an exhaustive list):  the MIPS measure specifications on the CMS Quality Program Payment (QPP) website; CMS training (when offered); your QCDR partner; and medical, professional, or compliance associations to which you may belong.  Any number of problems can be avoided simply by understanding your MIPS measures.  And, when there are problems that come up, you’ll be in a stronger position to address them if you know how your specific measures work.

Work With Your Qualified Clinical Data Registry (QCDR)

If you partner with a QCDR to submit your MIPS data, make sure they have all the documentation they need to submit your MIPS data to CMS.  This will include any outstanding audit documentation they need for their audit of your patient records; confirmation of the individuals or groups for whom MIPS data should be sent; and authorization to send the data.  I’m fairly certain I’m not supposed to say this but, I promise you, your QCDR isn’t asking for this documentation to torture you or your staff (even if it does feel like it).  They’re asking for it because it’s a CMS requirement that they get this documentation from you and review it.  Last, but not least, make sure you have a signed business associate agreement (as defined by HIPAA) with your QCDR.

Sharing Data From Your EHR

Again, for those who work with a QCDR to submit MIPS data, it’s important to make sure data from your EHR (whatever EHR you use) is being shared effectively with your QCDR partner.  You can get a view on this by making sure you receive regular benchmarking data, from your QCDR, throughout the year – and by checking the benchmarking results against the results you expected.  Discuss any discrepancies with your QCDR. 

Respond to Audits Timely

If you are subject to any audit surrounding your MIPS program, make sure auditors have all the available information they need well in advance of the MIPS submission deadline.  This will give you some space to correct errors and improve on future record keeping.  A QCDR cannot submit your MIPS data to CMS if audit responses are outstanding.

Timeliness is particularly important if you are working with a QCDR. And you’ll want to submit the documentation as early as possible rather than wait until right before the submission deadline.  Remember, your QCDR partner will be frantically trying to make sure all records and submissions are wrapped up in a bow tie and delivered to CMS well before the last-minute crush that risks causing the CMS submission portal to crash and burn. 

Consider Whether an Extreme and Uncontrollable Exception Applies

The last couple of years have been tough.  Depending on your circumstances, it may be more advantageous for you to apply for an ‘Extreme and Uncontrollable Exception.’ As always, it’s worth thinking about this option early and considering whether and under what circumstances this exception may be viable.  That said, the deadline for applying for an exception for PY2021 was December 31, 2021.  Still, this consideration holds good for future submissions.

So there you go folks – those are my words of wisdom for making the January – March MIPS season run just that bit more smoothly.  And for those of you who work with us on MIPS and who depend on us for accurate, timely MIPS submission and reporting, rest assured we are dedicated to making the MIPS data collection, reporting, and documentation process as simple and streamlined as possible.

Final Note: The closing of the 2021 MIPS data submission period for the 2021 performance period is March 31, 2022 at 8 p.m. Eastern Time (ET).