Medicare Compliance & Reimbursement

Tip: Keep tabs on your MVP status through the registration end date.

The clock is ticking on sending your Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) submissions for performance year (PY) 2023. And just because the reporting option is voluntary this year doesn’t make the process any easier.

Heads up: In a recent alert, the Centers for Medicare & Medicaid Services (CMS) reminds MIPS-eligible providers that it’s time to register to report an MVP as the window closes at 8 p.m. EST on Nov. 30. CMS began accepting applications for its newest Quality Payment Program (QPP) reporting option in April (see Medicare Compliance & Reimbursement, Vol. 49, No. 5).

Remember: “For the 2023 performance year, MVPs are a new, voluntary way to meet MIPS reporting requirements,” CMS emphasizes. “Each MVP includes a subset of measures and activities that are related to a specialty or medical condition to offer more meaningful participation in MIPS,” the agency alert explains.

Know These MVP Registration Essentials

Whether you intend to submit measures via traditional MIPS for the PY 2023, are interested in dipping your toe in the MVP waters, or plan to report under both, there are many program elements to work through once you meet the low-volume threshold and opt to go the MVP route.

First, before you send your MVP data to CMS, you must go through the MVP registration process — and that looks different depending on how you plan to participate in the program.

For example, if you’re an individual provider, you’ll fill out your registration application and include both your Taxpayer Identification Number (TIN) and National Provider Identifier (NPI), while an APM Entity would only attach the APM Entity ID that CMS assigned it. A group — which can be a single or multi-specialty — needs only its TIN. But a subgroup — two or more MIPS-eligible clinicians from the same group — requires an additional subgroup registration that must include the subgroup name, specialty-focus, and composition or how you intend to identify your group as a subgroup be it location, team, EHR sharing, or other reason.

Security Officials: For MVPs, HCQIS Access Roles and Profile System (HARP) information is required, and a designated QPP Security Official must be the point of contact in the system. QPP Security Officials are different from regular staff users and “are responsible for approving (or denying) role requests from additional users for their organization,” CMS says in a fact sheet on the role. This position is critical for MIPS management, “so they can view information about or perform an action [for the organization], such as submitting performance data, completing an opt-in election, or viewing performance feedback,” CMS explains.

Important: The process starts with opening a HARP account. You can find the instructions at CMS’ QIES Technical Support Office (QTSO) website at https://qtso.cms.gov/access-forms/harp-account-registration#:~:text=Register in the HARP system,verify his or her identity.

Once you set up HARP access, you can identify your QPP Security Official in the system using these steps:

• First, log into the QPP portal;
• Next, select “Manage Access;”
• Then, choose “Connect to an Organization,” and select the organization type. You’ll need an NPI, TIN, or the Provider Transaction Access Number (PTAN) you use to file Medicare claims;
• Last, the first user to log into the practice’s HARP account will automatically be made the QPP Security Official. Subsequent people logging in will be “staff users” and can only report data as opposed to the other list of things a QPP Security Official can do.

Once your registration goes through, “a QPP representative will follow up with you by email to confirm whether we’ve received all required information for the MVP registration and that the individual, group, subgroup, or APM Entity is eligible for MIPS,” CMS says on the MVP webpage. “We’ll leave the case open through the MVP registration period (April through November) as a way to track any changes or updates to your MVP (and, if applicable, subgroup) registration.”

During the registration timeline, if you lose your MIPS eligibility or fail to meet the low-volume threshold mandates, CMS will alert you through email that your MVP registration has been canceled. A final confirmation will come through in December 2023 if you’ve been approved to move forward, and on Jan. 2, 2024, your QPP account will reflect that your MVP registration is a valid reporting option, CMS indicates.

Bottom line: You can continue to update and change your MVP information in the system through the registration deadline. And just because you register, you’re still not required to submit an MVP, CMS advises.