The ACR’s MIPS Registry completes a pre-defined and CMS-approved process to determine whether individual MIPS-eligible physicians and physician groups have submitted accurate and complete data which satisfy MIPS reporting requirements. That validation process includes the following steps:



Benchmarking

Since 2008, the NRDR quality databases have been collecting quality measures and providing quality comparisons, for both facilities and physicians, to other physician groups across the country. For additional information about NRDR’s benchmarking capabilities as a QCDR, please see our related article on Benchmark Methodology



Verification of Eligibility for QPP 

MIPS participants in the Quality Payment Program (QPP) are asked to self-report whether they bill Medicare Part B, and the ACR randomly audits 20-30 physicians each performance year by comparing them to the Medicare Provider Directory. Additionally, the ACR examines each entity’s proportion of patients over 65 years old and compares that to the national average. Discrepancies are tagged for follow-up, and additional information and validation may be required for a physician’s continued participation in the QCDR.



Verification of NPI/TIN 

The MIPS registry requires a National Provider Identifier (NPI) upon enrollment for CMS submission and validates this entry against the NPI Lookup Web services from HIPAA Space. In addition to requiring all participating entities to attest to the accuracy and completeness of their information (including name, e-mail address and the NPI and TIN under which they bill Medicare), the ACR also reviews the documentation which all physician groups are required to upload to ensure its accuracy and relevance to the current reporting year. 



Calculation of Reporting Rate for Data Completeness

The MIPS registry calculates an entity’s reporting rate by dividing 

  • the count of records submitted to the registry (the numerator) by

  • the total number of exams relevant to a given measure (the denominator)

When calculating the reporting rate, the MIPS system automatically excludes ineligible records (e.g. inappropriate age) and uses a combination of SAS and SQL analytics for additional data manipulation (e.g. denominator exclusions). Alternatively, physicians can indicate that they have submitted 100% of exams to the registry, resulting in a reporting rate of 100%.



Calculation of Performance Rate

Performance rates for MIPS measures are calculated using CMS’ specifications which are available on the QCDR page. In contrast, ACR’s specifications, which are approved by CMS, are used to calculate the performance rate for non-MIPS measures. This performance rate is calculated for QCDR reporting the same way it is currently calculated for NRDR feedback reports. The registry feedback reports are at the level of facility or physician. Performance results, which are aggregated at the TIN level, can by accessed QCDR participants in the MIPS portal. 


For additional information, please see our related article on the MIPS Performance Report.



Verification of Measures

Upon registering their facilities for the QCDR, facility administrators are informed how many measures will be required from each of the three performance categories including Quality, Improvement Activities (IA), and Advancing Care Information (ACI). The MIPS registry validates their chosen measures in both quantity and spread (e.g. (lack of an outcome measure, fewer than six total measures) and periodically warns administrators to correct any selection deficiencies prior to CMS’ submissions deadlines. Additionally, facility administrators are also informed of the requirement that 50% of all eligible patients, from all payers, and at least one Medicare beneficiary must be reported.


Once CMS approves the QPP and non-QPP measures for the current performance year, the MIPS registry publishes this complete list including detailed specifications for reporting QCDR supported measures. The MIPS registry only allows approved measures to be selected for CMS submission, while still allowing unapproved measures to be included in feedback reports). Especially important, all changes from the prior year’s list of approved measures are highlighted to increase facility administrators’ awareness of the change.


Lastly, the MIPS registry provides web based tools and other resources to educate physicians and physician groups on all aspects of the MIPS performance categories. For additional information about MIPS performance categories, please see our related article on the Merit-based Incentive Payment System.



Audit

The MIPS registry uses native audit features built into all of the ACR’s registries and enhances those capabilities with additional checks specific to the needs of a QCDR. For example, following data upload, facility administrators have access to data quality reports which help administrators verify that their data submission did include all intended records and data elements. As an additional audit check, ACR staff randomly select and inspect 20-30 data quality reports each year, from which the ACR compiles and publishes (for the benefit of all facilities) general recommendations and tips to remedy data deficiencies.


Additionally, prior to submission to CMS, administrators are prompted to review their group’s procedure volumes (the denominator in a facility’s performance rate) and to verify the accuracy of all submitted data. Twice throughout the year, ACR staff inspect 10 patients at five randomly selected facilities to enhance administrator’s own quality checks. At the end of the submission period, ACR staff randomly select and inspect NPIs and TINs from 25 entities and validate alignment between supporting documentation and the reported IDs. 


All of this audit activity is conducted with the knowledge and consent of participating facilities as documented in the NRDR Participation Agreement. This agreement grants the ACR permission to randomly request and receive documentation from providers to verify data accuracy, as well give CMS access to review Medicare beneficiary data. Any gross inaccuracies in submitted data which are discovered during these audits will be communicated with CMS by e-mail within 30 days of discovery.