MACRA – MIPS: OIG Waves the Yellow Flag

Jim TateBy Jim Tate, EMR Advocate
MACRA/MIPS Subject Matter Expert
Twitter: @jimtate, eMail:

The Office of Inspector General (OIG) last week released the Followup Review: CMS’s Management of The Quality Payment Program (QPP). In 2016 OIG published their initial assessment of the management of the QPP by CMS. This secondary release was to access progress made since that time. You can follow the hyperlink and read the entire report but here is what you need to know. “OIG has identified two vulnerabilities that are critical for CMS to address in 2018 because of their potential impact on the program’s success”.

The OIG is waving a yellow flag based on two issues. Let’s check them out:

Vulnerability 1: “If clinicians do not receive sufficient information and assistance, they may struggle to succeed under the QPP or choose not to participate. This is of particular concern for small practices and clinicians in rural or medically underserved areas, who may lack the resources to fully engage in the QPP without customized technical assistance to meet practice-specific needs.” The QPP program is much more complicated than Meaningful Use and for those eligible clinicians impacted by MIPS scores the stakes are much higher in terms of reimbursement, practice value, and professional reputation. It is not an easy task to make appropriate decisions on which clinical quality measures to report or the best method to submit. It all adds up to being a complex jigsaw puzzle. The OIG is identifying the increased risk to practices “who may lack the resources to fully engage in the QPP without customized technical assistance to meet practice-specific needs.” Simply stated, in the zero sum MACRA – MIPS scheme the table is tilted away from those from practices “who may lack the resources to fully engage in the QPP without customized technical assistance to meet practice-specific needs”. That means smaller and rural based practices are at a disadvantage and this has been my concern from the begining.

Vulnerability 2: “If CMS does not develop and implement a comprehensive program integrity plan for the QPP, the program will be at greater risk of fraud and improper payments.” This is a core issue and the OIG has found this to be a snake with two heads.

  • “Potential vulnerabilities in the MIPS data submission system”: When 2017 MIPS data is submitted during the January – March 2018 period there will be functionality in place that will allow an instant review of the MIPS scoring as well as the opportunity to modify and resubmit the data. The OIG blows the whistle on what a “bad actor” will have the opportunity to do. However, these same functions make it possible for a user to “game” the submission system to obtain a higher MIPS score than the one to which the user is entitled, therefore potentially resulting in an improper positive payment adjustment…..If users are not satisfied with their first score, the system will permit them to go back, complete the checklist again with different answers, and see how that affects their score. Although users may resubmit their data to obtain the highest score to which they are lawfully entitled, this same resubmission process could be abused if users submit inaccurate data solely for the purpose of obtaining the maximum possible points.

“The accuracy of MIPS data submitted by clinicians”: “For the 2017 transition year, CMS indicated that its data validation efforts will focus on those clinicians who submitted fewer than the required number of quality measures and will determine whether the clinicians submitted all applicable measures for their specialty. Additionally, CMS incorporated data validation functions into its data submission system, but these automated checks were designed only to identify incorrect file formats and quality-measure data that do not make sense (e.g., a reported quality measure where the numerator is larger than denominator). CMS’s automated data validation processes cannot detect whether incorrect or falsified data are being submitted.

The window for data submission for the 2017 MACRA – MIPS year opens in two weeks on January 1, 2018. Two major integrity issues to the QPP have been identified by OIG but there are no ready solutions in sight. Practices with ample resources will have an advantage based on their ability to procure knowledge leading to the most strategic and beneficial MACRA – MIPS decisions. This is the oldest story on earth and since mankind crawled out of the caves inside knowledge has tipped the equity balance. The other issue, allowing instant scoring with the ability to modify data and resubmit, is fixable but don’t look for it to be done during the 2018 submission process.

This article was originally published on MIPS Consulting Blog and is republished here with permission.