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Essential Dos and Don’ts for a Successful 2024 MIPS Submission
Preparing for your 2024 MIPS submission? Avoid common pitfalls and maximize your performance score with these essential tips on what to do—and what to avoid—during the submission process.
The Do’s: Best Practices for MIPS Submission
To set your practice up for success, focus on these actionable steps:
- Prepare for Submission: Start by choosing your method— Will you be reporting through your EHR, QPP Portal, Registry, Claims, or a combination of these? Each has its unique requirements, so be sure your team and systems are fully prepared.
- EHR: Is submission method open/ready? Is there a version, patch, hotfix, etc. that is required? Are there open Known Issues impacting measure logic?
- Registry: Have you filled out appropriate data consent forms? Verified Tax ID?
- Claims: Only for small practices but have you checked QPP Portal to see if any claims-based quality measures were reported and tracked this year?
- QPP: Do you have the appropriate role and access in order to complete submission?
- Run Your Category Scores: Before submission, analyze your performance in each category—Quality, Promoting Interoperability (PI), and Improvement Activities (IA), even Cost. This will help you identify areas where you can make improvements.
- Quality: Remember small practice bonus and score measures using benchmarks!PI: Consider measure exclusion logic keeping in mind impact on score and future audit.
- i.e. eRX = 85/85 – you can exclude since under 100 but will it improve you score if your report vs. exclude? If it does not improve your score to include and still report it is at risk of being audited which if failed could cause payment recoupment
- Cost: CMS approved a new scorinRun Your Category Scores: Before submission, analyze your performance in each category—Quality, Promoting Interoperability (PI), and Improvement Activities (IA), even Cost. This will help you identify areas where you can make improvements.Quality: Remember small practice bonus and score measures using benchmarks!PI: Consider measure exclusion logic keeping in mind impact on score and future audit.i.e. eRX = 85/85 – you can exclude since under 100 but will it improve you score if your report vs. exclude? If it does not improve your score to include and still report it is at risk of being audited which if failed could cause payment recoupment
IA: Don’t forget small practice vs. large practice reporting requirements – only report number of activities needed to earn 100% in this category. Pick activities that align with eCQMs or actions your practice is already performing – remember there is no current requirement to select different activities year or year.
Cost: CMS approved a new scoring logic for this category – make sure to review your feedback compared to previous years to understand the impact.
- Quality: Remember small practice bonus and score measures using benchmarks!PI: Consider measure exclusion logic keeping in mind impact on score and future audit.
- Understand Approved Extreme & Uncontrollable Circumstances Hardship Impact: If your practice qualified for an automatic EUC hardship due to a natural disaster or you filed one claiming an EUC for 2024 reporting, you are safe from penalty and not required to submit data, however any data submitted to CMS will override the hardship and you will be score if data is received for 2 or more categories.
- Reporting PI & IA and using EUC to exclude from Cost & Quality? If you are a small practice, make sure to check you have no claims-based measures that were submitted throughout the year. Consider checking previous years if any claims-based measures were reported.
- Save All Documentation: Keep detailed documentation for all information submitted to CMS in the event of a Data Validation Audit (DVA).
- Quality: Performance reports, visit/patient detail reports for denominators, numerators, and exclusions.
- PI: Performance reports, visit/patient detail reports, SRA, SAFER guide, registry enrollments or production data, CEHRT ID, PDMP examples, bi-directional HIE evidence, etc.
- IA: Documentation supporting activity attestation with screenshots, reports, practice policies, program enrollments, certifications, etc.
- Assess Financial Impact: Calculate how your score might affect your payment adjustment and how your payment adjustment impacts your Medicare reimbursement for a calendar year. Remember, poor performance could result in a penalty of up to –9%!
The Don’ts: Avoid These Common Mistakes
Avoid these pitfalls to stay on track and maximize your score:
- Ignore Claims-Based Quality Data: For small practices, claims-based submission may be being submitted due to legacy PQRS reporting and impact score or reporting strategy – Don’t forget to check QPP!
- Neglect Exporting Audit Documentation: Export audit documentation now to support a future audit. Systems used for reporting can change and legacy data may be inaccessible 6 years from now!
- Forget About Scoring Changes: Every year, CMS may finalize changes to the formulas or criteria that determine how your performance is scored. These changes could affect which categories are more heavily weighted or how points are allocated.
- Inaccurate score calculation: Preliminary scores are no longer available in the QPP portal for MIPS. Make sure you can calculate an accurate score estimate in order to optimize your reporting strategy and final score!
As you finalize your 2024 MIPS submission, use the experience as a learning opportunity. Discuss pain points with your clinical teams, identify areas for improvement, and start building a strategy for 2025 MIPS reporting, including frequent measure performance review.
We’re here to help! If your practice is unsure about how to proceed email us at GovernmentIncentives@dashealth.com, and let’s make sure your 2024 MIPS submission is accurate, complete, and maximizes your final score. Together, we’ll help you achieve the best results possible while limiting practice burden through strategic prioritization.