Missed your SRA in 2017? Here’s How to Avoid a MIPS Penalty

First, do your HIPAA Security Risk Analysis immediately to reduce chances of a breach while maintaining compliance with all Federal reimbursement programs. With just mere days left before the March 31st MIPS submission deadline, if you have not already pulled together the necessary documentation for the previous calendar year, it is the time to do so! For all those last “minute’ers,” we have some guidance to assist in your efforts.

One of the most important concepts to understand about the 2017 MIPS program is the grace that is being extended by CMS.  In fact, 2017 is being considered a “transitional year” meaning providers do not need to have all three measurements in place to avoid penalties and gain incentives – GOOD NEWS! As a reminder, these measurements include: Quality Measures, Advancing Care Information (security risk analysis required) and Improvement Activities.

While at HIMSS last week, we reached out to CMS and received the following guidance for providers:

The provider does not need to submit to the advancing care category at all if they did not perform the SRA.  They can optionally do so but they will not be able to earn a advancing care performance category score if they select no to the measure. Here is a link to our 2017 Quality Payment Program Resource Library  which includes many guides on the Quality Payment Program.  Included in the Resource Library, there is the MIPS 101 Guide which includes the pick your pace test option on page 15 and 17 and describes the submission of 1 quality measure OR 1 improvement activity will ensure that the provider will avoid a negative payment adjustment. Some key information on the process of submission is included in the Data submission fact sheet  and a Merit-based Incentive Payment System (MIPS) data submission video.” – CMS Division of Health Information Technology

Additionally, if the provider is in an Alternative Payment Model (APM) group, CMS broke down the groups below:

For Shared Savings Program Participants

“ACOs in the Shared Savings Program submit quality measures to the CMS Web Interface on behalf of their participating providers and MIPS eligible clinicians.  The Shared Savings Program measures and corresponding benchmarks will also be used to determine the MIPS quality performance category score for all MIPS eligible clinicians in each ACO. Therefore as long as your ACO submits all of the required Shared Savings Program Web Interface measures, then you do not need to report the MIPS quality performance category separately.”

For Next Generation ACO Model Participants

“ACOs in the Next Generation ACO Model submit quality measures to the CMS Web Interface on behalf of their participating clinicians.  The Next Generation ACO measures and corresponding benchmarks will also be used to determine the MIPS quality performance category score for all MIPS eligible clinicians in each ACO.”

For All Other MIPS APMs

“Under the Quality Payment Program, the APM Entity group in these APMs will not be required to report  quality in the first MIPS performance period.  This does not change any CMS requirements to report quality measures as part of your participation in the APM.”

A few important FYI’s related to penalties:
  • To Avoid the 4% Penalty – Providers must submit something, at least one item from one of the measurements listed above
  • To Avoid the Penalty and ATTEMPT to Earn a Positive Payment Adjustment – Providers can participate partially and CMS determines payment based on what is submitted
  • To Avoid the Penalty and RECEIVE a positive payment adjustment – Providers will need to participate for the full year and complete all measurements
  • If No Participation or Action is Taken – A 4% penalty will be applied

In the event your workplace did not conduct a HIPAA security risk analysis in 2017, you can still avoid the 4% penalty by submitting something from the other measurement categories (Quality or Improvement Activities.)

Finally, there is no time like the present to complete a bona fide HIPAA Security Risk Analysis! Checking this box will immediately reduce your changes of a breach while maintaining compliance with all Federal reimbursement programs. Get started today!

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