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We're sharing proven strategies that help us optimize our clients' MIPS scores!
IMPROVEMENT ACTIVITIES (IA)
The IA Category is worth an easy 15/100 MIPS points.
Choose 2 or 4 measures (depending on your group size or QPP-assigned "special status") that your clinicians are already doing in their day to day activities. That's it.* Work with your clinicians to select measures that align with organizational and/or community goals and patient initiatives.
My favorite IA measures are:
Advance Care Planning
Collection and use of patient experience and satisfaction data on access
Engagement of patients through implementation of improvements in patient portal
Implementation of improvements that contribute to more timely communication of test results
Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
Use of telehealth services that expand practice access
*The bare minimum for attesting to an IA measure is at least 50% of your ECs must conduct the activity for at least 90 days.
PROMOTING INTEROPERABILITY (PI)
CMS hasn't significantly updated the PI Category requirements in awhile, making success in these measures low hanging fruit especially for those who have participated in Meaningful Use/MIPS over the last several years.
If you are a group of >15 ECs under a single TIN, the PI Category is worth 25/100 MIPS points.
If you are a Small Practice (< 15 ECs under your TIN), the PI Category is automatically reweighted to zero, adding 15 points to the IA Category, for a total of 30/100 MIPS points plus 10 points to the Cost Category, for a total of 40/100 MIPS points.
H O W E V E R, even if you are a small practice, it is often the best strategy to report PI measures to improve the overall MIPS Score. When is this the case?
Your Quality Score is not strong (< 90/100).
Your Cost Score is unknown. This basically applies to everyone since Cost was reweighted automatically in 2021 and 2022.
Your Cost Score is not strong (<20/30).
Remember, to successfully receive a score in the PI Category, ALL measures are required to be reported/attested to, unless you qualify for an exclusion. More on that HERE.
QPP has put together an excellent PI User Guide. Use this to jump-start your PI participation and if you have questions, don't hesitate to email me @ michelle@mavinhealth.com.
QUALITY
The Quality Category is worth 30/100 MIPS points. To succeed, you must choose 6 measures, collecting data for at least 70% of the eligible population for each measure (known as data completeness). Then, be sure to follow the next steps for success!
Use your EHR or a Third Party Registry to collect, analyze and even report quality measures. If you're still coding claims for quality, you are flying blind which makes it extrememly hard to succeed. You need to use technology that provides performance transparency.
Stay up-to-date with quality reporting requirements, measure additions/deletions and measure logic, which change annually.
Choose the right measures for YOU. Select measures that align with your specialty, practice initiatives and patient population. Not sure which measures apply? Use this Quality Measure Search Tool.
Choose measures with benchmarks and measures that allow for the maximum of 10 points. Each measure performance is scored differently! A 90% performance in one measure can equal 9 points, where a 90% performance in another measure may only give you 4 points.
Success in MIPS is a team effort. Identify the stakeholders, which typical include an EHR specialist, clinician leader and IT, at minimum. Start meeting with them early in the year. Assign responsibility for training staff and provide reminders regularly.
Work with your EHR vendor and/or Registry to learn the specific workflows for the measures. This applies to both the PI and Quality measures. They are the only ones that can give you the specific steps that must be followed for your measure numerators and denominators (and exceptions/exclusions as applicable in quality) to increase.
Analyze regularly! Again, this applies to both the PI and Quality measures. Diligent, routine data analysis for integrity and performance are critical to the success in the Quality Category. I suggest you block your calendar weekly to start, then expand to every-other-week and eventually monthly once measures are selected, workflows have been optimized and performance is improving.
Need more help with the MIPS program?