Practice Management Alert

Hint: Keep your registration deadline in mind to maximize your flexibility.

The year is quickly coming to an end, and that means there’s little time left to submit your Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) information for performance year (PY) 2023. The reporting is voluntary this year, but that doesn’t mean that the process is any easier.

MIPS-eligible providers should mark Nov. 30 on their calendars now; the Centers for Medicare & Medicaid Services (CMS) recently announced that the deadline for registering to report an MVP closes at 8 p.m. EST on that day. CMS has been accepting applications for the new Quality Payment Program (QPP) reporting option since April.

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.

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, here are some of the program elements you will need to work through once you meet the low-volume threshold and opt to go the MVP route.

Explore These MVP Essentials

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: MVPs require Health Care Quality Information Systems (HCQIS) Access Roles and Profile System (HARP) information, 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.

Start the Process via Registration

The process starts with opening a HARP account. You can find the instructions at CMS’ Quality Improvement & Evaluation System (QIES) Technical Support Office (QTSO) website at https://qtso.cms.gov/access-forms/harp-account-registration#:~:text=Register.

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.

Hint: 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.

Sift Through the Nitty Gritty on MVP Selection

This year there are 12 MVPs that cover a variety of specialties. For individuals, groups, subgroups, and APM Entities reporting an MVP, the Cost, Quality, and Improvement Activities performance categories will be MVP-specific, while Promoting Interoperability and Population Health will be part of a “Foundational Layer,” CMS guidance indicates.

You can cross-reference the MVP, specialty-focus, and MVP ID, which is associated with the MVP measures selection, in the chart below: