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Identify and Avoid These Common MIPS Reporting Mistakes

Identify and Avoid These Common MIPS Reporting Mistakes

By Michele Caravan

Here’s how can you identify and avoid these common MIPS reporting mistakes

At ReportingMD we see plenty of reporting and scoring traps when it comes to reporting performance data. As these programs become more complex and the risk of penalties larger, organizations face an ever-steepening climb to incentive payments.

Over the past 17+ years we’ve witnessed the challenges and traps, so that our clients don’t have to.  Here are 5 tips to help you avoid the most common issues facing you for 2022.

Meeting the minimum criteria for penalty avoidance is a risky game for several reasons:

  • Category weights can differ by several different criteria. Misunderstanding your MIPS category scoring scenario could mean your plan for minimum scoring might not be enough to avoid penalty
  • CMS has the authority to change and remove benchmarks throughout the year for several different reasons. A minimum scoring strategy could implode if CMS takes this action on any of your MIPS measures

Beginning with this (2022) reporting year, the penalty threshold is at its highest, of 75 points. Submitting the minimum on only one category (e.g. Quality) will not enable you to avoid the penalty.

Avoid topped-out measures

Measure selection is one of the most important considerations for performance. Topped out measures can be capped at fewer points and you can only achieve those points with a perfect 100% score in the measure. If you are reporting measures that are topped out, you could be at risk of penalty even with a nearly perfect score!

  • If possible, avoid selecting measures that do not have a benchmark.
  • Avoid selecting measures in which you have fewer than 20 eligible events.
    • Measures with fewer than 20 eligible events will not be scored against the benchmark
  • Avoid selecting measures in which you have no performance score.
  • Avoid selecting measures in which you cannot report on at least 70% of all payer eligible events, meeting the minimum data completeness threshold.

EHR reporting can be problematic

  • The limited number of reportable electronic Clinical Quality Measures (eCQMs) means that organizations will be competing in a much smaller pool of available measures, and that those measures will top out faster.
  • Not all EHRs offer all eCQMs so check to make sure your EHR offers the eCQMs you plan to report.
  • If reporting through your EHR, make sure to report using the discrete data fields your EHR has configured for MIPS reporting.
  • Remember, CMS now allows practices and clinicians the ability to report using different submission methods, and CMS will combine all data for scoring. If your EHR doesn’t offer a measure you would like to report, ReportingMD can help report that measure as a qualified registry.

Self-reporting through claims is also a dangerous game

  • Only small practices (15 or fewer clinicians) are allowed to report via the claims method
  • Only individual reporting is allowed when reporting through claims. You cannot report as a group, so you need to manage each measure for each provider individually.
  • If your data completeness is below the 70% threshold, small practices will only earn 3 points per measure.
    • Tracking data completeness when reporting through the claims method is difficult so you may not know you reported <70% until it is too late
  • Claims reporting also allows for a lot of uncertainty since you cannot track your progress or analyze your measures

Reporting through CMS Web Interface is a risky move

CMS Web Interface reporting means that when the submission window opens, CMS will provide the practice a list of eligible beneficiaries and the measures to be reported.

  • The practice must submit the clinical action result for 10 different measures for 248 beneficiaries from a CMS generated list without any knowledge of who will be included in that list.
  • The practice has no say in the selection of measures, when reporting through CMS Web Interface, the measures are preset by CMS.

The MIPS program is complex and creates many opportunities for failure. Even seasoned experts can find themselves in tough situations when navigating these programs.

ReportingMD can help prepare you, update you, and deliver the best results for you when it is time for submission.