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The Last 90 Days of MIPS Reporting: Maximizing Performance and Ensuring Accuracy.

As we approach the final 90 days of the MIPS performance period, it’s time to focus on refining your data, improving performance, and securing the highest possible score. The steps you take now can significantly impact your future Medicare reimbursement rates. Here’s why this final stretch is critical and how you can make the most of it.

Why the Last 90 Days Matter

  • Final Reporting Period: The last quarter represents the final phase of the performance year. It’s your last chance to gather and finalize data for submission.
  • Ensuring Data Accuracy: This is the time to double-check that the data collected throughout the year is accurate and complete. Any discrepancies could negatively affect your MIPS score.
  • Last-Minute Adjustments: With performance trends in hand, you can make adjustments to improve care delivery and optimize your scores before the performance year ends.
  • Impact on Reimbursement: Your performance now directly influences your MIPS score, which determines future Medicare reimbursement rates.
  • Opportunities for Improvement: Focus on underperforming quality measures and implement strategies for improvement in this final stretch.

Know your Deadlines:

  • October 3, 2024: Last day to start a 90-day performance period for Improvement Activities.
  • October 11, 2024: 2023 MIPS Exception Hardship for Change Healthcare deadline
  • December 2, 2024: MIPS Value Pathway (MVP) registration ends.
  • December 31, 2024:
    • 2024 Performance Year (PY) ends.
    • Exception applications for PY 2024 close.
  • March 31, 2025: MIPS reporting deadline for 2024 data submission.

Confirm Your MIPS Eligibility

Log into your QPP account to confirm eligibility, or search your National Provider Identifier (NPI) to determine eligibility based on Medicare billing, patient count, and services provided. Be aware of new reporting requirements for clinicians like physical therapists, dieticians, speech-language pathologists, clinical psychologists and more.

Exclusions:

Check if your clinicians qualify for any special statuses which may require less reporting! Clinicians in small practices (under 15 NPIs per Tax ID) or those participating in APMs or ACOs may be exempt from certain categories like Promoting Interoperability (PI). Review exclusions carefully to avoid unnecessary reporting.

The Quality Category Reminders

  • Run reports more frequently
  • Review your measures carefully. Some, like BMI, are no longer available as individual measures in 2024.
  • Make sure the measures you have chosen have a benchmark! Even scoring 100% won’t make a difference if the measure you selected is only worth 3 points.
  • Hold more frequent meetings with your consultant and/or staff and be sure to delegate responsibilities effectively.

Promoting Interoperability Category Reminders

In 2024, PI reporting includes several required measures, and new requirements have been introduced:

  • Make sure you are tracking data related to eRX, patient portal and HIE data exchange for a full 180-days! It is no longer 90 days.
  • Verify Your EHR Status: Ensure you’re using 2015 CURES Certified EHR Technology (CEHRT). Check your status via the Certified Health IT Product List (CHPL).
    • Make sure you are aware if an upgrade, patch, hotfix, etc. are required for reporting!
  • Complete and update your Security Risk Analysis and SAFER guide! This is not submitted with your data to CMS, but is required in case of a MIPS Data Validation Audit.
  • Make sure your clinicians are using our state’s Prescription Drug Monitoring Program (PDMP/PMP) and save down examples of patient lookups.
  • Ensure you know your action plan for immunization registry and electronic case reporting – are you planning to exclude? Claim active engagement level 1 or 2?
  • Other Tips & Tricks:
    • Automate where you can! Many EHRs offer automation for patient portal enrollment, or interfaces for HIEs that can provide full credit on measures.
    • Confirm you have to report PI – Small practices and many other special statuses may allow you to exclude from this ENTIRE category. There is no benefit to reporting on it unless it will improve your overall MIPS score, it is just another set of measures CMS can audit you on in the future.

Improvement Activities Category Prep

  • Make sure you save down documentation related to your improvement activities for over 50% of your providers (if reporting Group) and it is dated during your 90-day reporting period.
  • Select activities that can be auto-validated or are recommended by your EHR or Registry vendors if they offer this
  • You can submit the same activities as previous year’s – there is no need to reinvent the wheel!
  • Only submit what is needed to earn a 100%, extra activities will not earn bonus points and will still require documentation if audited.

The Cost Category Prep

  • The Cost category is calculated automatically based on Medicare claims data—no submission required.
  • Make sure there are no hardships available that apply to your practice for 2024 that could allow you to exclude from this category.
  • Review your previous cost scores through your QPP account to identify opportunities for improvement. This will provide insights into your current score, which is based on CMS’s analysis of claims.

By staying organized and focused, you can make the most of your MIPS score in 2024 and earn a positive payment adjustment! Our team of Government Incentives experts are here to help. We can provide an ROI analysis showing the financial impact MIPS has on your practice.  Don’t hesitate to reach out just to talk one of our team members here: governmentincentives@dashealth.com

You can also access free educational webinars here and view our most recent historical webinar here.