Boost Your MIPS Score: Pitfalls to Avoid, Tips to Follow

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$1.2 billion! That’s how much IRIS Registry users are estimated to have saved by avoiding pen­alties during the first five years of the Merit-Based Incentive Payment System (MIPS). More practices could have avoided MIPS penalties if they had stayed current on Academy guidance and steered clear of some common pitfalls.

Use the Academy resources. For ophthalmology-specific guidance, bookmark the Academy’s MIPS hub page (aao.org/medicare/mips) and use the 2023 IRIS Registry Preparation Kit and EyeNet’s MIPS 2023: A Primer and Reference (see “Two Key Resourc­es”).

Who Do You Contact About IRIS Registry Issues?

IRIS Registry support has transitioned to Verana Health from FIGmd. The EHR integration process is being tran­sitioned from FIGmd to Verana Health, which is the Academy’s exclusive end-to-end data partner for the IRIS Reg­istry. Likewise, support for manually reporting MIPS via the IRIS Registry is also transitioning to Verana Health for the 2023 performance year. If you have a question, you can either contact your Verana Health Practice Experience Manager or email irisdatalink@veranahealth.com.

Tip—if you have been reporting MIPS using the IRIS Registry (either manually or via EHR integration) and haven’t yet heard from Verana Health, they might not have current contact information for your practice. If you suspect that this might be the case, email irisdatalink@veranahealth.com.

Tip—when emailing Verana Health, speed up communications by including your practice name and IRIS Registry ID.

Don’t Let Personnel Changes Knock MIPS Off Course

From staff turnover to changes in an individual’s MIPS status, consider how practice changes can impact your MIPS reporting.

Problem—the MIPS point person left the practice and wasn’t replaced. Tip—appoint a MIPS back-up point person.

Problem—a clinician’s MIPS status changed. Tip—at the start of each year, check the MIP status of your practice’s clinicians. (See “What’s Your MIPS Participation Status?” on page 16 of the MIPS Primer.)

Problem—your practice failed to notify the IRIS Registry vendor about changes in clinicians, staff, or locations. Tip—if you are reporting MIPS via IRIS Registry–EHR integration, you must notify Verana Health as soon as possible if the electronic records of a new clinician or a new practice location need to be incorporated into the IRIS Registry. You also should keep your practice’s IRIS Registry account current as to clinicians’ MIPS status.

Don’t Miss These Critical Email Communications

Throughout the year, Verana Health and the Academy send IRIS Registry emails with important information about deadlines, process changes, and program updates.

Problem—your practice is not receiving email from Verana Health. Tip—these messages are sent to the contact person that Verana Health has on file, so check that it has the correct contact information. You can contact Verana Health at irisdatalink@veranahealth. (But you should first check your spam folder!)

Problem—your practice is not receiving the Academy’s monthly IRIS Registry blasts. Tip—these emails are sent to the contact person that Verana Health has on file (see previous tip).

Problem—your practice is not checking Washington Report Express and Practice Management Express for MIPS news and deadlines. Tip—Wash­ington Report Express is sent to Acade­my and AAOE members on Thursdays and Practice Management Express is sent to AAOE members on Sundays. If you haven’t been seeing these news blasts, you may need to update your communication preferences: first, go to https://secure.aao.org/communications to ensure that you have opted in to all Academy communications; next, click the “Manage my email preferences” link that appears at the bottom of most Academy emails to manage which com­munications you receive.

Measures and Activities—Don’t Overlook Any Options

Don’t assume that what you did in past years will be the best option for 2023. There are many quality measures and improvement activities available, so make some time to consider all your options.

Problem—not reviewing your quality measure choices each year. Tip—for 2023, more of the measures developed for the IRIS Registry have benchmarks than ever before, and there are brand-new quality measures that have a 7-point floor. Review the quality measure benchmarks in the MIPS Primer (Table 4, page 26) to see which measures are likely to give you the highest score.

Problem—assuming that no im­provement activities are suitable for ophthalmology. Tip—see “Improve­ment Activities—at a Glance” in the MIPS Primer (Table 7, page 53). This year, there are 10 additional improve­ment activities that can be reported via the IRIS Registry. Once improve­ment activities have been selected, make sure that clinicians know the activity specifications. Also, establish a workflow that will enable you to retain the necessary documentation in case of an audit.

Don’t Underperform on Any Measures

It is harder to avoid a penalty than it was during the early years of MIPS, which makes it more important than ever to maximize your scores on performance rate–based measures and to not miss any steps on promoting interoperabili­ty’s (PI) all-or-nothing measures.

Problem—not checking measure specifications. Tip—measure specifica­tions can change each year. Make sure your practice understands the specifica­tions for all the measures that you plan to report, and update internal work­flows as needed. For quality measure specifications, see the appendices of the Preparation Kit. For cost measure speci­fications, see the CMS Resource Library at https://qpp.cms.gov. Specifications for PI measures and improvement activities also are available at the CMS Resource Library and will be posted at aao.org/medicare/mips.

Problem—waiting until the end of the year before manually reporting quality measures. Tip—if you are re­porting manually via the IRIS Registry, it is best to report measures at least monthly. You also will need to keep track of the data-completeness totals for manually reported quality measures (see page 25 of the MIPS Primer).

Problem—not monitoring measure performance rates. Tip—catch problems with performance rates while there is still time to do something about them.

Problem—underperforming on the PI measures. Tip—one area of un­derperformance involves the Provide Patients Electronic Access to Their Health Information measure. There have, for example, been cases where practices have provided patients with access to their medical information online but this wasn’t documented in the EHR system. For pointers on im­proving your score for this measure, see aao.org/practice-management/article/mips-tips-provide-patients-electronic-access.

Reporting via IRIS Registry-EHR Integration?

While IRIS Registry–EHR integration has proven to be the least onerous way to report quality measures, there are still problems to avoid.

Problem—not notifying Verana Health of key changes to your EHR system or practice management system, such as an upgrade or a change to a new vendor, a network server change, or a transition to a cloud-based system, Tip—don’t miss the June 15 deadline for notifying Verana Health of these changes. You may need to repeat the data mapping process.

Problem—not monitoring your quality measure performance rates in the IRIS Registry. Tip—if you suspect problems with your MIPS data, there are several possible causes:

Data mapping issue. If your EHR system indicates that specific patients met a quality measure’s requirements, but the IRIS Registry indicates that they didn’t, the discrepancy may be due to a data mapping problem. Report the discrepancy in the Zendesk for Verana Support. (See the Zendesk for Verana Support User Guide in the Preparation Kit.)

Data entry error. It’s important to catch data entry errors early in the year. This way, staff can undergo additional training on proper procedures, the EHR data can be reentered, and the corrected data can be repulled into the IRIS Registry.

Lack of clinician awareness. You may need to update clinicians about which quality measures are being re­ported and what information needs to be recorded in the EHR.

Failure to notify Verana Health about new clinicians. Double-check that data for all your practice’s clini­cians are being pulled into the IRIS Registry.

Let the Preparation Kit Walk You Through MIPS Reporting

Whether you are using the IRIS Reg­istry to report MIPS manually or via EHR-integration, the 2023 IRIS Registry Preparation Kit describes the role of your practice’s MIPS point person, outlines a schedule of what you need to do throughout the year, and provides extensive information on all the quality measures that can be reported via the IRIS Registry (see “Two Key Resources,”).