MIPS 2020 Reporting: Strategies to Succeed

Experts agree: COVID-19 is likely to speed up the healthcare industry’s transition from volume- to value-based care. The transition has providers looking more closely at the Quality Payment Program (QPP), including the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) – already shown to help providers more aptly respond to the pandemic, according to a recent survey by Premier.

The Centers for Medicare & Medicaid Services (CMS) designed MIPS to tie payments to quality, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce cost. There are four MIPS categories that measure progress in these areas and make up a clinician’s total score: Quality, Promoting Interoperability, Improvement Activities and Cost.

While reporting can be complex, it does not have to be a burden. With a strong reporting strategy, registries can relieve clinicians of the last-minute stress of assembling data and choosing a reporting pathway.

Here are three things clinicians can do now to successfully report MIPS in 2020.

1.Determine your eligibility.

Not all clinicians are required to participate in the MIPS program. For those that are, there are multiple reporting requirements and pathways to choose from depending on the clinicians’ classification in categories such as practice billing volume, rural or underserved location, hospital-based practice, alternative payment model participation or non-patient-facing care. These classifications can change annually, so clinicians should verify their eligibility each MIPS performance year.

CMS has made it easy for clinicians to determine their eligibility through the Quality Payment Program website. Simply enter a National Provider Identifier (NPI) in the QPP lookup tool to determine MIPS eligibility, review any special statuses and understand options for reporting.

2.Understand which measures are key for practice reporting.

The Quality category of MIPS requires the most attention because clinicians must select measures, collect data and submit to CMS, and it is the highest-weighted component of the final score. Clinicians should not only consider which measures best reflect their specialty and practice, but also which measures have the potential to earn them the highest scores based on published benchmarks. Another consideration is to align MIPS measures with the practice’s existing quality strategy and goals.

To get started, we recommend creating a draft list of measures that are relevant to the practice, then reviewing the specifications and benchmarks for each one. If a measure has been tracked by the practice before, compare the practice’s past performance to the measure benchmarks to get an estimate of how many points it would earn. Note that it’s important to look for changes in requirements, codes or benchmarks as they can change annually. CMS-approved MIPS registries are required to calculate results based on the current year’s specifications, ensuring that all providers are being measured against the same standards. Check that the required data elements are readily available in the practice’s data systems to minimize the burden of data collection.

If measures can’t be selected in advance, that’s okay, too – CMS-approved MIPS registries, including Premier’s, provide a listing of supported measures on the QPP website, allowing clinicians to choose the best registry for their individual or group needs.

3.Select the best registry for your practice.

There are many registry options for satisfying MIPS reporting requirements, and selecting the best one is dependent on the unique needs of each practice. Once the targeted quality measures have been determined (above), the next step is to assess the practice’s capabilities and preferences for submitting data to a registry. This should include a survey of how data is collected within the practice and whether the information systems are capable of extracting the necessary data elements. Key questions to explore could include:

• Does the electronic health record (EHR) offer automated data feeds to certain registries?
• Does data reside in multiple source systems, such as a billing database, medical records or the scheduling system?
• Will manual entry of data into the registry be needed?

Premier’s registries include options for automated data submission from selected EHR vendors, electronic file transfer from any system as well as direct manual data entry. Premier’s Qualified Clinical Data Registries include:

• The Premier Clinician Performance Registry
• The Renal Physicians Association (RPA) Quality Improvement Registry*
• The National Osteoporosis Foundation (NOF) Quality Improvement Registry*
• The National Home-Based Primary Care & Palliative Care (NHPBC) Registry*
• The American College of Physicians (ACP) Genesis Registry

_{*Manual data entry options available for 2020 reporting}

Get Started to Receive Ongoing Feedback

Practices should utilize their MIPS registry throughout the year for performance monitoring, feedback and improvement. Depending on the method the practice utilizes, a clinician can – and should – get started early. The Quality category performance period is the full calendar year (12 months). The sooner data collection begins, the sooner clinicians will receive performance feedback and can begin improvement work.

Learn more about Premier’s comprehensive clinical data registry portfolio, including measure listings per registry.

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Further Reading:

• The Ins and Outs of Hospital Quality Star Ratings
• Eliminating Care Variation: AdventHealth ensures all patients are treated with the latest evidence-based guidelines. Here’s how.
• The Foundation of Performance Improvement: How benchmarking analytics fuel Baptist Memorial Health Care’s Mission.
• We’ve Improved Maternal Outcomes Before – Here’s How to Replicate the Success: Maternal health quality improvement has been done remarkable well before with the reduction in early elective deliveries.