MIPS Action Plan

Eligibility

Check your MIPS participation status by entering your individual NPI at https://qpp.cms.gov/participation-lookup. You could be eligible if you answer yes to all three of the following questions:

1. Do you invoice $90K or more in Medicare Part B allowed charges?
2. Do you have more than 200 Medicare Part B patients?
3. Do you provide more than 200 covered professional services to Medicare Part B beneficiaries?

If you answered yes to all of the questions, and you are one of the clinician types listed here, you may be subject to MIPS. Some eligible clinicians could be eligible for an exception. Find out more here.

Take Action

Now that you have confirmed your eligibility for the MIPS reporting year, it is time to start learning the requirements. You can access any of the recorded MIPS training session via Tebra University and you can also use any of the resources listed below.

• CMS Incentive Programs
• Quality Payment Program

Our CMS Incentive Program site has a variety of options for you to learn about the various requirements you might be subject to.

• Training in Tebra University
• Run a Quality Measures Report
• Quality Measures Guides

Get Ready

Let the following checklist serve as a reminder of the tasks that must be completed to help you be better prepared for the MIPS reporting year:

• Confirm clinician eligibility and determine their QPP track: MIPS or APM or both
• Create a MIPS Audit Binder for the current performance year
  Tip: Building an audit binder for every attestation year allows attesting clinicians to easily access their documentation in the event they are selected for an audit. Review the EHR Incentive Program Audit FAQ to learn more about audits.
• Select six quality measures
• Select a submission method. You may choose to submit Quality measures via claims, registry, or QRDA upload
• Go to Improvement Activities and select 2-4 Improvement Activities. Save your supporting documentation in your audit binder
• Complete a Security Risk Analysis or do a reevaluation of your existing security risk analysis.
• Review the High Priority Practice Guide of the Safety Assurance Factors for EHR Resilience (SAFER Guide).
• Activate the Patient Portal
• Set up ePrescribing for your clinicians
• Register with your state to begin the process for Immunization Registry submission (if applicable), then create a Customer Care case to complete the interface setup
• Register with your state to begin the process for Electronic Case Reporting submission (if applicable), then create a Customer Care case to complete the interface setup
• Register with UpDox for Direct Messaging (required to Send/Receive and incorporate summaries of care). A clinician should register first, then other staff members
• Set up eLabs. Or, create lab/studies orders in the patient’s charts when ordered by paper then manually add and sign off results.

Monitor Your Progress

It is important that reports are run and reviewed at least once or twice per month. All items on Your Checklist must be completed as early in the year as possible. Some of these items can significantly impact your scores.

• Monitor your reports for the Quality and Promoting Interoperability measures in Clinical (EHR).
• Modify your workflow as needed to ensure that any given score is improving.
• Take training on CMS Incentive Programs again if needed.

Attestation Submission Period

Finally, prepare for your attestation and submission of data. The attestation submission period is January 1st to March 31st of the year following the performance year. It is crucial that you:

• Go to Tebra University and find the MACRA /MIPS course. Register for an Attestation Webinar - delivered only during the attestation period (Jan-March).
• Run your final Quality report for the full calendar year and download in QRDA format-- unless you reported quality measures via claims.
• Run your final PI report for the reporting period of your choice.
• Gather the supporting documentation for your selected Improvement Activities.
• Select a registry (unless you are reporting quality measures via claims or QRDA submission).
• Save your final reports in your MIPS audit binder and keep the binder for a minimum of 6 years.
• Create a HARP account to submit your attestation.
• Submit your MIPS data to CMS by March 31st.