Beginning in June 2019, the Centers for Medicare and Medicaid Services (CMS) will begin performing data validations and audits on the 2017 and 2018 performance years of the Merit-based Incentive Payment System (MIPS).
CMS has contracted with Guidehouse, a consulting company formerly part of the PwC network, to perform the validation and audits on a select number of MIPS eligible clinicians and groups. Selected providers will receive a request for information directly from Guidehouse via email or by certified mail. Once received, providers have 45 calendar days from the date of the notice to provide the requested information.
To comply with the validation and audit, clinicians and groups will send data that supports their MIPS participation. For instance, for an improvement activity like “Expanded Practice Access: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record,” CMS suggests sending the following documentation:
- Patient Record from EHR – A patient record from an EHR with date and timestamp indicating services provided outside of normal business hours for that clinician; or
- Patient Encounter/Medical Record/Claim – Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits.
As another example, for quality measures providers may need to send a file with patient CPT codes, ICD-10 codes, ages, etc., as indicated in the numerator and denominator criteria of each quality measure.
If providers use a third party to report MIPS performance categories, those vendors also will assist in the data validation and audit by providing source documentation used for inputs and calculations. As well, third party vendors are required, as a condition of their participation in the MIPS program, to provide the contact information for all individual clinicians or groups for whom they submit data, including phone number, address, and, if available, email.
It’s important to remember, also, that MIPS requires all-payer data, not just Medicare data, for all data submission mechanisms with the exception of claims and the CMS Web Interface. This information will also be required for data validation and audits. According to CMS, the data from payers other than Medicare will be used for informational purposes to improve future validation efforts and will not be the only source of data used to make final determinations on whether you pass or fail an audit.
As these audits get started, providers should keep in mind that the False Claims Act requires them to keep documentation up to six years, and, as finalized in the CY 2018 Quality Payment Program final rule, CMS may request any records or data retained for MIPS purposes for up to six years. Federal regulation also mandates compliance with these data sharing requests, and those who do not provide the requested information may be the target of further action by CMS, including possible future audits.
For more information about the MIPS data validation and audits, review the following:
- 2017 MIPS Data Validation Criteria – Lists the 2017 criteria used to audit and validate data submitted in each performance category, along with recommended documentation to support providers’ performance (AUTOMATIC DOWNLOAD FROM CMS)
- 2018 MIPS Data Validation Criteria – Lists the 2017 criteria used to audit and validate data submitted in each performance category, along with recommended documentation to support providers’ performance (AUTOMATIC DOWNLOAD FROM CMS)
The Quality Payment Program also can be reached at QPP@cms.hhs.gov or 1-866-288-8292 (TTY 1-877-715- 6222), Monday through Friday, 8:00 AM-8:00 PM ET.
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