Medicare Compliance & Reimbursement

Tip: Back up measures’ submissions with documentation and dates.

As CMS maintains a steady stream of rollbacks, turnarounds, and upsets, it’s easy to get discouraged by all the policy mayhem. Providers have a lot on their plates already with ramped-up claims scrutiny from Medicare carriers, RACs, CERT auditors, and more. And now Merit-Based Incentive Payment System (MIPS) submissions are under the audit microscope, and experts suggest its not a matter of if, but when.

2019 status reminder: Remember, the 2019 Quality Payment Program (QPP) participation standards were scaled back for Performance Year 3. Now, MIPS-eligible clinicians (ECs) must meet three requirements under the low-volume threshold.

Those participation requirements include:

• submit at least $90k in Part B allowed charges;
• administer care to at least 200 Part B beneficiaries; and
• provide at least 200 covered fee-schedule services.

Use your National Provider Identifier (NPI) and check your 2019 MIPS participation status at https://qpp.cms.gov/participation-lookup.

But, for QPP Year 3, CMS is allowing Medicare providers who meet one or two of the low-volume threshold requirements to opt-in for a payment adjustment to their 2021 pay. There is also a voluntary-reporting option for clinicians, who don’t meet any of the benchmarks; however, voluntary submitters won’t receive any payment adjustments — positive or negative — to their 2021 payments.

Plus, ECs with high 2019 MIPS-composite scores stand to gain a 7 percent 2021 payment, and possibly bag a 10 percent bonus for an exceptional performance, the QPP Year 3 fact sheet says.

Warning: However, just because you keep on top of your MIPS measures doesn’t mean you’ll get that aforementioned payment bump. In fact, the 2017 MIPS results show that performance data submissions do not necessarily translate to big wage increases for the majority of ECs (see Medicare Compliance & Reimbursement, Vol. 45, No. 3).

The lackluster performance increases may also have contributed to the initiation of CMS’s MIPS targeted review program to help providers better understand why they didn’t get that elusive raise. A plethora of MIPS 2017 guidance from experience reports to targeted review explanations to payment adjustment FAQs were recently uploaded to the QPP resources’ page for ECs to peruse. Providers can expect MIPS 2018 performance data to be available soon, as the attestation window closed last month.

Why Does CMS Audit MIPS Data?

In simple terms, CMS is bound by the law to audit MIPS providers to certify performance data in both pre-incentive and post-incentive reviews. This ensures that the program remains successful and “operates with accurate and useful data,” indicates the 2019 MIPS data validation criteria fact sheet. And by checking MIPS submissions often, the agency also hopes to improve providers’ data management.

“Chances are pretty good that you’re eventually going to undergo an audit if you haven’t already,” says Lora Woltz, ONC HIT certification manager in the Eye Care Leaders April 25 webinar, “Bulletproofing the MIPS Audit File.” Here’s why: “CMS audits between 5 and 10 percent of their providers every single month,” she stresses.

Details: Supporting documentation is key to backing up your attestations. For random prepayment audits, that usually means data for the most recent year of MIPS attestation, Woltz advises. “The [prepay] information requested is fairly predictable,” and you must comply with data requests before you can receive your incentive pay, Woltz maintains.

The postpayment MIPS audits occur after incentive payments have been received, and CMS can revoke the incentive payments for non-compliance. These audits are “almost always done as part of an investigation into data that are deemed inconsistent or inaccurate, and because of this, the information requested will be more specific and focused,” Woltz explains.

Keeping in line with False Claims Act (FCA) mandates, ECs will need to hold onto performance documentation for up to six years, according to the CY 2019 QPP final rule.

MIPS auditors can do a postpayment audit up to and including six years after you submit performance attestations. So, for the Quality, Promoting Interoperability, and Improvement Activities performance categories, you’ll need to keep extensive attestation data for those six years following, possibly longer.

However, “since the Cost measure is calculated through administrative claims you will not be responsible for providing any documentation in this category,” instructs Cherie Kelly-Aduli, CEO of QPP Consulting Group in Mandeville, Louisiana and a MedAxiom consultant, in a MedAxiom blog post.

Other timelines: In addition to safeguarding six years worth of MIPS data, you must consider two other important deadlines. You must acknowledge the audit correspondence within 14 days, counsels Woltz. Also, similar to other CMS audit types, you’ll have 45 days to send your supporting documentation, she indicates.

Outside contact: CMS currently contracts with Figliozzi and Company for MIPS audits for Medicare while the individual states determine the auditors for Medicaid attestations, Woltz says.

And although MIPS audits are different from claims reviews, the punishments are similar. Failed audits will lead to paybacks while fraudulent behavior may land you with exclusion from Medicare, fines, or prison time.

Resource: Find MIPS 2017, 2018, and 2019 attestation and payment advice at https://qpp.cms.gov/about/resource-library.