Making sure you prepare for an audit BEFORE the audit…
This strategy makes audits as stress free as an audit can be. So, while you are preparing your MIPS data for submission, make sure you have copies of the following:
The Certification ID for the CEHRT version(s) you used during the performance period. This could be a 2014 and/or a 2015 certified version.
Using the website, https://chpl.healthit.gov/#/search
Search for Allscripts Professional
Click the Cert ID+ to add all EHR versions used during the performance period to your cart
How can you tell which versions you were on during the reporting period?
Go to back office reports
Create and run the Allscripts Product Install report for the same performance period
Click the Get Certification ID button to generate the ID. Print a copy for your records.
Quality Measures:
Whether you are MIPS, an APM or an AAPM, you will need the actual report data validating the Denominator, Denominator Exception, Denominator Exclusion, and Numerator for each individual NPI (if you are submitting for your individual providers) or for the group (if you are submitting as a group). I have not ever had to submit the actual patient details, but technically, they could ask for them.
Since your reports are run electronically, you are not excluding patients from those reports and are therefore reporting on 100% of your patients. This is your data completeness number. Consider a notarized statement or attestation letter that includes your level of data completeness.
Improvement Activities
Evidence that your practice has implemented one or more improvement activities.
This evidence might be written meeting minutes from reviewing patient satisfaction surveys, reports from back office reports to prove same day access to care, or other improvement activities that are customarily tracked by Patient Centered Medical Home.
Advancing Care Information (MIPS only)
A copy of each report to validate the data you are submitting to CMS.
A summary of your security risk assessment and date of review.
Proof of active engagement with the Immunization Registry if you have a live interface.
Proof of active engagement with a Specialized Registry Reporting if you have a live interface.
Proof of active engagement with a Syndromic Surveillance Reporting if you have a live interface.
Active Engagement is the process of moving towards sending “production data”. There are 3 options: 1) Registration complete and waiting to submit, 2) Testing and Validation, and 3) Production.
We will offer classes in January to discuss submission and documentation in more detail and to answer any additional questions you might have.