MIPS data validation and audit begins for performance years 2019, 2020 and 2021
December 16, 2022

MIPS data validation and audit begins for performance years 2019, 2020 and 2021

The Centers for Medicare & Medicaid Services (CMS) has contracted with Guidehouse to conduct data validation and audits of MIPS eligible clinicians in accordance with the legislative authority set forth in 42 CFR 414.1390(a)-(d). This regulation requires MIPS eligible clinicians or groups to comply with data sharing requests, providing all data as requested by CMS. Data validation and audits are designed and conducted to confirm the accuracy and completeness of reported results of the MIPS program.

If you are selected for MIPS data validation and audit, you will receive a request for information from Guidehouse. The request will be e-mailed to selected clinicians via the MIPS DVA contractor’s email address (MIPS_DVA@guidehouse.com).

You will have 45 days from the date of the notice to provide the requested information of substantive, primary source documents. These documents may include copies of claims, medical records for applicable patients, or other resources used in the data calculations for MIPS measures, objectives, and activities. Primary source documentation also may include verification of records for Medicare and non-Medicare patients where applicable

Please note, failure to provide the requested information for the data validation and audit could result in a payment adjustment. To help avoid this, CMS has the following data validation and audit resources available on the Quality Payment Program Resource Library:

For more information email the QPP helpdesk at QPP@cms.hhs.gov.

Attesting to Improvement Activities via NACOR

Clinicians can start attesting to 2022 Improvement Activities in the NACOR Dashboard if the practice is reporting as a group. A step-by-step tutorial on attesting to an IA in the NACOR dashboard is available here. For practices with multiple Tax ID Numbers (TIN), make sure the correct TIN is listed in the drop-down menu before attesting to the activity.

As participants of NACOR, practices can attest to activity IA_PSPA_1: Participation in an AHRQ-listed patient safety organization. This is a medium-weighted activity worth 10 points.

To earn full credit for the Improvement Activity Component, you must earn 40 points. Medium-weighted IAs are worth 10 points and high-weighted activities are worth 20 points. If the practice or clinician qualifies for a special status, these points may be doubled.

For more information, email askaqi@asahq.org.

Review your NACOR dashboard

Practices that have recently uploaded new data files should review the NACOR dashboard as it allows you to monitor your providers' performance, as well as pinpoint any problems with the data and make necessary corrections prior to data submission deadlines.

Data completeness requirements for the 2022 MIPS Performance Period are:

  • Submit 12 months of data (January – December 2022).
  • Report a minimum of six measures with at least one outcome or high priority measure.
  • Measure must meet the 20-case minimum to be scored.
  • Reporting rate must be at least 70% of all eligible cases across all payers for each measure reported.

Note: The minimum point threshold to avoid a negative payment adjustment has increased from 60 to 75 points for the 2022 performance year. It is important to check the measure performance rates for your practice to make sure the measures reported will earn the maximum points allowed for the Quality Component.

As a reminder, section 8 of the Addendum for Quality Reporting to the NACOR Participation Agreement states that your practice "and each EC agree, and Participant shall require each EC, to review his/her measure results in AQI at least four times a year and provide timely feedback to AQI on the measures that will be reported on the EC's behalf."

If there are questions about the dashboard results, submit a ticket to nacorsupport@asahq.org.

December Quality Reporting Office Hours

The December office hour slides and recording are now available on the AQI website.

Holiday Coverage

The ASA/AQI offices will be closed Friday, December 23 through Monday, January 2. An AQI staff member will be available for urgent matters December 23 and December 27-30. If you have an urgent issue, email askaqi@asahq.org a staff member will assist you.

Happy Holidays!

2022 Reporting Deadlines

NACOR Registration: October 3, 2022

January through November 2022 data submission: January 31, 2023

Individual Quality Reporting Consent Submission: January 31, 2023

Improvement Activity Attestation: January 31, 2023

CMS Opt-Out for Individual Reporting: January 31, 2023

TIN/NPI Reconciliation: January 31, 2023

All data submissions: February 15, 2023

Contact AQI

Register: qcdr@asahq.org

NACOR Dashboard support: NACORSupport@asahq.org

Ask AQI: AskAQI@asahq.org

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