Jackie Rogers is manager of the Quality Reporting Engagement Group at AmerisourceBergen. Jackie helped build the group back in 2011 when it started as a M.U.S.T. program, intended to provide the very first Meaningful Use attestations in the country for clients. Since then, she has expanded the group into a robust consulting practice. Before joining AmerisourceBergen, Jackie traveled the country implementing EPIC (Electronic Health Record), working at Stanford University Hospital and Clinics, Cedars Sinai Hospital, and Mt. Sinai Hospital in New York City.
A checklist to prepare for and submit documents for Merit-based Incentive Payment Program (MIPS) reporting under CMS' Quality Payment Program.
Your practice is already gathering the data on the measures for the Merit-based Incentive Payment Program (MIPS) reporting under CMS’ Quality Payment Program (QPP). But how do you know you will have all the documentation in place and not scrambling at the end of the year? A documentation checklist would come in handy, especially if you are one of the thousands of practices audited after data submission.
The steps to prepare for data submission, and a brief explanation, are outlined below:
Data Submission Preparation (How Will You Report Your Data to CMS?)
EHR Readiness and Implementation
Eligible Clinician and Group Information (Who Should Submit MIPS Data?)
Advancing Care Information (ACI) Documentation
Quality Measures Documentation
Improvement Activities Documentation
Documentation maintenance is paramount to your success, should your practice/eligible clinician be selected for an audit. A Book of Evidence is critical for organizing and keeping everything together year after year of successful regulatory reporting, and can help a practice retain several thousand dollars received in incentives. Having proper documentation can be the peace of mind you need to focus on more patient-centered priorities for your practices. Practice administrators can relax, knowing they have done their due diligence. When they receive an audit notice, having the Book of Evidence ready can avoid scrambling and would only require an upload of files to the auditor.
CMS recommends maintaining documentation for at least 6 years for each year of attestation/submission of data. The Book of Evidence should be kept in both hard and electronic copies and stored alongside your updated HIPAA policies/procedures and training materials for best practice and organizing efforts.