MIPS Tips: Communicate and Take Action

Thursday, May 17, 2018 | Cherie Kelly-Aduli

MIPS Tips: Communicate and Take Action

One of the benefits of working with many different programs and practices is that I am exposed to the full range of quality and efficiency . . . to both successes and failures. For example, I have clients that scored well below 70 points in 2017 and others that scored in the 90s. I even had one with a perfect 100. My goal is to always take those experiences and share lessons learned so that my other clients won’t make the same mistakes, or will feel confident in trying to duplicate what has worked.

In looking at the differences between the low scoring and high scoring groups, one factor became very clear: with low scoring programs there were consistently too many cooks in the kitchen and a lack of communication between key stakeholders.

When there are too many hands in the pot there tends to be a lot of talking and not much action. I can remember one group from a few years ago that had a physician leader who did not want to get on board with the ACO project. He felt the MSSP/ACO Track One measures didn't apply to the specialists under the Tax ID. I knew even though we didn't agree with the measures chosen by CMS, there was no way of getting around them, so I created a work plan with firm deadlines for training clinic staff on each of the measures. The provider continued to give me excuses for why the plan wasn't going to work. There came a time when we could not stand still any longer so I went off the rails and rolled out the work plan without his blessing. Once we had the list of attributed beneficiaries we were able to fill the gaps in care by having support staff call the patients and set up annual wellness visits. If the patient did not have a PCP, then it was a great opportunity to have them see one in our network. This process helped us not only meet the web interface measures but also created a lot of downstream revenue for the practice. With a CMS shared savings payment over $800,000, sometimes you just need one person to pull the trigger on the project and have your team help you execute the plan.

Miscommunication or no communication is a chronic problem that I see in the lower scoring groups. If the CEO or Lead Physician in the ACO example would have sent out an email to every provider and employee of the medical group stating that we were participating in an ACO in addition to the proposed work plan, it would have made everyone’s job easier. I was met with resistance by almost every physician I encountered because they were unaware that we were even participating in an ACO.

. . . sometimes you just need one person to pull the trigger on the project and have your team help you execute the plan.

With the above in mind, let’s get down to the specifics of how you can improve your MIPS outcomes. Do you have a solid strategy in place to avoid the 5% Medicare Part B penalty for non-participation in the MIPS program for 2018?  We are now in May, which means your quality and cost scores have been ticking in the background since January. Listed below are some of the tips that can help you get started if you haven't already.

  • Plug your NPI into the MIPS lookup tool to see if you are an eligible clinician. This link will take you to the CMS QPP homepage.
  • Decide if you are going to participate as an individual or group.
  • Assign a point person to keep track of your scores weekly or monthly. This project manager will need to review results with key staff members.
  • Review your first 90 days of data for the Quality and Advancing Care categories in your CEHRT. Create a work plan with realistic training dates to address low scoring measures. Since your Quality measures weigh the most, start there then move to Advancing Care. I would address one measure at a time every two to three weeks. 
  • Review your Security Risk Analysis from 2017 and make changes/updates to your written policy.
  • Review the quality benchmarks for your proposed submission method. They are available in the CMS Resource Library. Keep in mind that the specs have changed. Click here; select 2018 resources by provider type and topic then "Quality Benchmarks." 
  • Check the current weight of your 2018 Improvement Activities.
  • Reach out to your EHR vendor to see if your measures are mapped correctly in 2018 to meet the updated measure criteria.
  • Plan to review the 2017 MIPS feedback reports. They should be available from CMS in July of 2018.
  • Review your Field test results for Episodes of Care. This report is available on your CMS EIDM account if you were attributed 10 or more episodes during the measurement period (6/1/2016 - 5/31/2017).

It’s not too late to get started with your 2018 MIPS audit preparation. You will first want to start with screenshots of the NPI lookup tool then move through each category. The Practice Improvement Category will be the trickiest to document. Keep in mind that your activities in this category should demonstrate consistent and meaningful engagement within the period for which you are planning to attest.


Reach out to MedAxiom if you need help choosing the right Quality measures, creating a work plan to address training on low scoring measures or preparing your MIPS 2018 audit documentation. We are always here to help.


MedAxiom’s blog post is published every Thursday.



Illustration: Lee Sauer

About the Author
Cherie Kelly-Aduli

Cherie Kelly-Aduli is the CEO of QPP Consulting Group in Mandeville, Louisiana, and a MedAxiom consultant. She has over 16 years of experience in healthcare operations, population health and accountable care. Prior to opening her own firm, Cherie was the Director of Clinical Operations and subsequently Director of Population Health and Accountable Care for the Louisiana Heart Hospital and Medical Group located in Lacombe, Louisiana.

Throughout her career Cherie has been highly successful in efficient practice management, practice adoption of electronic health records, and assisting providers with exceeding standards for patient satisfaction. As payors and patients have transitioned to "pay for value," Cherie has been instrumental in leading private practices and hospital systems to achieve high quality outcomes under the Meaningful Use, PQRS and Value Based Modifier programs; she is now assisting groups with their adoption of the Merit Based Incentive Payment system under MACRA.

To contact, email: caduli@medaxiom.com

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