MIPS Dashboard

To track and submit MIPS measure performance as a group, you can navigate to the self-serve Program Enrollment page. If you encounter any issues on the Program Enrollment page, you can open a support case to request that the MIPS group reporting option be enabled for your practice.

Note: Your practice must have at least two MIPS-eligible clinicians.

1. On the Main Menu, click Support > Success Community > Contact Client Support Center to enter your quality management case.
   
2. Include the following information in your case.
• TIN
• Set of measures
• Request group reporting or both group and individual reporting
3. Click Create Online Case.
   A case confirmation page appears with the case number.

You can enroll MIPS-eligible clinicians through the Program Enrollment page. However, athenahealth automatically enrolls eligible clinicians in MIPS on your behalf (see Eligible clinicians (ECs) for MIPS).

If you experience any issues with the Program Enrollment page, you can open a support case for assistance.

Eligibility is updated daily.

To check the eligibility, enrollment, and composite performance score (CPS) of clinicians in your practice:

1. Display the MIPS Dashboard: On the Main Menu, click Quality > MIPS Dashboard.
   
   Note: If you are an eligible clinician, your own information appears at the top of the list.
2. Review the list of MIPS-eligible clinicians.
   Note: MIPS data is submitted for each TIN/NPI combination. Clinicians who practice under multiple tax IDs have more than one row and more than one set of data.
3. Check the MIPS eligibility of each clinician in the Eligibility column.
   Note: The eligibility status shown on the MIPS Dashboard is determined based on an interface (API) with the CMS Quality Payment Program (QPP) website. If the eligibility status includes the alert icon , click the icon to display information about any mismatch between the QPP and athenaOne data.
4. Check the enrollment status of each clinician in the Status column.
5. To view measure-level details for a specific clinician, click the clinician's row (see To view a Clinician Report Card and sign off on data).

Per the requirements of the MIPS program, the MIPS Dashboard tracks measure data for each eligible clinician and tax identification number (TIN) combination (that is, at the TIN/NPI level).

Note: Clinicians who practice under multiple tax IDs have more than one row in the Practice Performance view and more than one set of data.

To review or compare the measure-level performance of clinicians in your practice:

1. Display the MIPS Dashboard: On the Main Menu, click Quality > MIPS Dashboard.
2. Click the Performance menu and select Measure Performance.
   
   
3. Review or compare the measure-level performance of clinicians in your practice. You can review the following information for each clinician or TIN:
• Measure — Measure name as it appears on the Quality tab of the patient chart.
• Category — Relevant MIPS category name.
• Num/Den — Numerator and denominator (for numeric measures).
• Satisfied — Non-benchmarked measure performance, calculated as numerator/denominator, less excluded patients.
• athenaOne Average — Average performance for this measure of all participating clinicians across athenaOne. This column allows you to see how you're performing on the measure compared to other clinicians in our network.
  Note: For an athenaOne performance average to appear for a measure, at least 20 individuals or groups must be enrolled in the measure, and each individual or group must have at least 20 patients in the denominator. If the minimum threshold for enrollments (20) or the minimum number of patients in the denominator (20) is not met, the message "Insufficient Data" appears in the athenaOne Average column.
• Points — Number of points achieved for each measure, as received from CMS.
4. To sort data in the Measure Performance view by any column, click the arrows next to the column name.
• Sort by Measure to compare performance, by measure, across clinicians.
• Sort by Category to review measures by category (for example, all Improvement Activity (IA) measures), across your practice.
• Sort by Satisfied to identify the highest and lowest performing measures, by clinician, across your practice.
5. Click the arrow next to the column name again to display the list in ascending or descending order.

You can filter data in the Measure Performance view by clinician, TIN, and category.

1. Display the MIPS Dashboard: On the Main Menu, click Quality > MIPS Dashboard.
2. Click the Performance menu and select Measure Performance.
   
   
3. To filter data by clinician or TIN, click Select next to Filter on the left side of the page.
   
   The Filter window opens.
4. Click Clinician or TIN on the left side of the Filter window, and then select the filter options on the right side of the window (for example, clinician names).
5. Click Apply to view the filtered measure data.
6. To filter data by a category, select an option in the Category filter on the left side of the Measure Performance view.

athenahealth is a CMS-approved qualified registry for the MIPS program. A qualified registry collects MIPS data from MIPS eligible clinicians and submits the data to CMS on their behalf. CMS requires you to review your category performance data and sign off on that data electronically before athenahealth can submit. As a qualified registry, athenahealth will submit data for the MIPS Quality, PI, and IA categories on your behalf if submission requirements are met, including your submission sign-off.

By default, individual clinicians and groups are enrolled in the year-long MIPS Promoting Interoperability (PI) program for submission, but you can instead submit data for any 180-day period, assuming reporting requirements have been met. You can see performance and submission support for these MIPS PI programs on the Quality Management Reporting (QMR) and MIPS Dashboard pages.

Note: If you already performed any attestations for this reporting year — for example, the Security Risk Analysis (SRA) or the Information Blocking attestation — these attestations are carried over automatically when you move from the default one-year program to a custom reporting period.

To request a 180-day program for a specified date range, submit a case as follows.

1. On the Main Menu, click Support > Success Community > Contact Client Support Center.
   The case classification page appears.
2. Click the Quality Management category.
   The Quality Management subcategories appear.
3. Click Quality Program Enrollment and then click Create Online Case.
   The case creation page appears.

4. Enter the required information (for example, the clinicians or groups to enroll in the custom MIPS PI program and the date range for the reporting period).
   

5. Click Create Online Case.
   A case confirmation page appears with the case number.

If clinicians in your practice are billing Medicare in athenaOne and are eligible as defined by CMS, you can enroll through the Program Enrollment page. If you experience any issues with the Program Enrollment page, you can open a support case for assistance.

Eligible clinicians are assigned a composite score based on their performance across all four threads of work (see MIPS Scoring). This score ultimately serves as a modifier on their Medicare Part B reimbursements.

Note: MIPS reimbursements (incentives/penalties) apply only to Medicare Part B claims.

Additionally, athenaOne runs a script daily to enroll individual clinicians in MIPS. This script uses the CMS Quality Payment Program (QPP) status to retrieve eligibility. Individual clinicians with an "Eligible Individual Clinician" status are automatically enrolled in MIPS.

Note: This script works on individual clinicians only. To enroll a group in the MIPS program, see To track and submit measure performance as a group.

MIPS eligibility information for each clinician and TIN appears in these views of the MIPS Dashboard:

• Practice Performance view — Eligibility column
• Clinician Report Card view — Eligibility field at the top of the report card
  
  

The eligibility status shown on the MIPS Dashboard is determined based on an interface (API) with the CMS Quality Payment Program (QPP) website. In some cases, athenaOne cannot match clinician data with QPP — for example, an NPI may not be recognized as a valid NPI, or we may be unable to match the medical group in QPP with a TIN address in athenaOne. In cases where the eligibility status needs attention, click the alert icon to display information about any mismatch between QPP and athenaOne data and how to address the issue.

Note: The QPP site is the ultimate source of truth about clinician MIPS eligibility. If you notice an issue in athenaOne, open a support case so that we can investigate an incorrect match or status (see To view MIPS eligibility, enrollment, and practice performance).

Clinicians not required to participate in MIPS include:

• Eligible clinicians newly enrolled in Medicare for the reporting year.
• Clinicians participating in an Advanced APM who are meeting the required thresholds.
• Clinicians with less than $90,000 in Medicare Part B charges.
• Clinicians who care for fewer than 200 Medicare Part B patients.

Note: If a clinician is not required to participate in MIPS, you can still enroll the clinician to gain experience in the program (request that the clinician be enrolled in the MIPS Quality "Not for Attestation" program).

To unenroll from the MIPS program, please submit a support case from athenaOne > Support > Success Community > Contact Client Support Center.

Note: If you previously requested that a specific clinician be unenrolled from the MIPS program, we will not re-enroll that clinician, even if their eligibility status with QPP has changed.

If a clinician is enrolled in MIPS but does not yet have a full year of eCQM data, a prompt on the MIPS Dashboard encourages the clinician to import eCQM data from another EHR.

MIPS Quality Program category submission requirements are documented under Quality: Traditional MIPS Requirements in the Quality Payment Program website and states in the Data Aggregation section the requirement to report a full 12-month performance period even if you transitioned to a new EHR by aggregating data from the previous EHR with the new one. Note that aggregation of electronic Clinical Quality Measures (eCQM) is only possible and necessary when the TIN being used is the same in both EHRs.

If you need to aggregate, see To import QRDA I files.

Note: athenahealth only supports the aggregation of eCQMs and does not support data aggregation for MIPS CQMs in athenaOne.

If you do not want athenahealth to submit your MIPS Quality Program data but would still like to use the Quality Management Reporting page to monitor your performance in athenaOne:

• You can navigate to self-serve Program Enrollment page to enroll in the MIPS Not for Attestation option, if you prefer that athenahealth does not submit on your behalf.

• Alternatively, you may open a support case to request unenrollment from the MIPS Quality program and enrollment in the MIPS Quality "Not for Attestation" program instead.

• You can then aggregate your athenaOne quality data with non-athenaOne data outside athenaOne for submission on your own.

To help maximize your MIPS incentive payments, quality managers and clinicians can access the MIPS Dashboard, where you can:

• Check clinician eligibility and enrollment.
• Track and submit measure performance individually or as a group (if you have two or more MIPS-eligible clinicians).
  Note: CMS will accept both individual and group submissions, and then take the best score of those submissions for each clinician.
• View your CMS preview scores for these categories: Quality, Promoting Interoperability (PI), and Improvement Activities (IA). The preview scores are calculated by CMS based on your enrollment in athenaOne.
  Note: Cost category data does not appear on the MIPS Dashboard. For information about the MIPS Cost category measures, refer here.
• View Clinician Report Cards.
• Record an approved exception to one or more MIPS quality performance categories to prevent the submission of data for the exempted performance categories.
• Identify opportunities to improve performance.

Note: Custom MIPS programs and MIPS programs that are labeled as "Not for Attestation" do not appear on the MIPS Dashboard. To track the performance of clinicians enrolled in these MIPS programs, use the Quality Management Reporting page.

The MIPS Dashboard includes these views:

• Practice Performance — List of eligible clinicians and medical groups that shows enrollment and MIPS composite performance scores.
• Clinician Report Card — Overall progress and measure-level performance, as well as any submission requirements, for the selected clinician or medical group.
• Measure Performance — Measure-level performance for all clinicians and medical groups.
• Administration — Administrative tasks such an indicating a MIPS exception status to record an approved exception for one or more performance categories.

Practice Performance view

 

When you display the MIPS Dashboard, you see the Practice Performance view.

Tip: From other views of the dashboard, click Dashboard at the top left of the page to return to the Practice Performance view.

 

You can use the Practice Performance view to:

• Review a list of MIPS-eligible clinicians at your practice. Clinicians are listed from lowest scores to highest scores.
  Note: If you are an eligible clinician, your own information appears at the top of the list.
• Confirm that your eligible clinicians are correctly enrolled in the program to help ensure you avoid penalties. We require eligible clinicians to be enrolled in our programs and meet submission requirements in order to submit your data to CMS.

• Click on an individual eligible clinician's name to see their performance.

• Review prior year’s performance.

• View the composite performance score (CPS) of all enrolled clinicians.
  
• Access Clinician Report Cards.

Note: Clinicians who practice under multiple tax IDs have more than one row and more than one set of data because MIPS data is submitted for each TIN/NPI combination.

 

Clinician Report Card view

 

To access a Clinician Report Card, click a clinician row on the Practice Performance view of the MIPS Dashboard.

 

The Clinician Report Card is a clinician-centric view that lets clinicians and practice managers:

• Review performance data (composite performance scores and measure performance). This performance data helps clinicians and practice managers understand how their measure performance will translate into overall success in the MIPS program. This helps you identify specific measures or eligible clinicians to focus on to maximize performance. Use this view in tandem with the patient-level data available in the Quality Management Report (QMR) to gain a detailed understanding of measure performance.
• See any remaining MIPS objectives.
• See whether public health registry (PHR) measures are satisfied or not satisfied.
• See whether these Promoting Interoperability category requirements are satisfied or not satisfied: Security Risk Analysis (SRA), Prevention of Information Blocking attestation, and SAFER Guides measure attestation.

• Tracking the overall progress you are making on your total score.

• Complete submission: See Submission status.

 

athenaOne displays category scores received from CMS for these categories:

• Quality
• Promoting Interoperability (PI)
• Improvement Activities (IA)

Your MIPS preview scores are updated daily, typically by noon Eastern time.

 

The Clinician Report Card CPS and category scores reflect the athenahealth official Submitted data score (when it exists) and the Score Preview Athena for data not submitted by athenahealth.

• Green bars represent the CMS-returned score associated with data officially submitted on your behalf by athenahealth. These final scores consider all data submitted by athenahealth on your behalf.
• Purple bars represent the CMS-returned anticipated score for data in athenaOne.
• Blue bars represent the athenaOne score preview that appears during the reporting year, before CMS returns its official score preview in the fall of the reporting year (see Score Preview Athena).
  
  
  
  T​​​​​he athenaOne Average score will display for all measures on the MIPS Dashboard. This shows the average performance of all participating clinicians across athenaOne on these measures. It allows you to compare how you are performing to other clinicians on our network who are tracking the same measures. See the section highlighted in yellow below.
  
  

All measure-level scoring details come directly from CMS.

 

You can sort the data in the Objective Status section by clicking any column title.

 

Score Preview Athena

 

Before CMS publishes its official score preview in the fall of the current reporting year, an internal score — Score Preview Athena — is shown on the Clinician Report Card view of the MIPS Dashboard in blue. The internal algorithm that generates the athenaOne score preview is a close approximation of the CMS scoring logic and includes these categories:

• Quality
• Promoting Interoperability (PI)
• Improvement Activities (IA)

These scores provide an approximation of your performance on MIPS measures throughout the year prior to the official score preview that is released by CMS later in the calendar year.

Note: Cost Category performance is not included in the internal scoring algorithm; therefore, you may see discrepancies between the scores from CMS and the score preview from athenahealth. However, it will show small practice bonus points if your practice is indicated as a small practice via the API with QPP.

 

The category scores — shown as a fraction under each progress bar in the Category Breakdown section — reflect the weighted scores for each category. As a result, you may see different category values for each year, but your overall scores remain the same.

 

Your MIPS final, category and measure scores may be impacted by actions or inactions by the user including:

• Sign-off status: If sign-off is not completed for SRA, Complete Actions to Limit or Restrict Interoperability of CEHRT Attestation and SAFER Guides, your PI score will be 0.

• EUC Exceptions

  • You can apply for an EUC Exceptions or it may be automatic. Learn more about EUCs here.

  • If you indicate an exception in the Administration section of athena's MIPS dashboard for one or more categories, your category and composite scores will update based on EUC reweighting (applies to individuals and groups). As a reminder, submitting two or more categories will negate the EUC.

  • Note: You must be enrolled in a category for EUC reweighting to factor into your score apart from Cost for individual clinicians.

Greater visibility into your submission status to help clinicians and groups identify actions to enable submission. There are a variety of checks that calculate into the Score Preview athena to indicate whether your MIPS data is ready for submission. The following table describes the various Submission Statuses and the actions if any that may be required in order to proceed with submissions. The submission statuses are: Processing, Pending Action, Submitted, Submission Failed, Requirement unmet.

Eligibility Status	Composite Score Passed	Submission Status	Action
Eligible/Opted-in/QP/MIPS APM/Ineligible	N/A	Pending Action	If enrolled in MIPS PI, SRA, Complete Actions to Limit or Restrict Interoperability of CEHRT Attestation and SAFER Guides attestations are mandatory. If enrolled in CQM measures, data sign-off is mandatory. To enable submission, please complete signoffs or raise a support ticket on the Success Community
Unknown	N/A	Pending Action	We are unable to match your athenaOne information with the QPP participation data.   Submission is not enabled for Registry / CQM, PI or IA. Submission is enabled for Quality eCQMs.
Opt-in and Not opted in the QPP tool	N/A	Pending Action	You need to make an opt-in election on the QPP portal for us to enable submission.
Eligible/Opted-in/QP/MIPS APM/Ineligible	Yes	Processing	Data is being updated and will be processed for submission during the submission time frame. If enrolled in MIPS PI, SRA, Complete Actions to Limit or Restrict Interoperability of CEHRT Attestation and SAFER Guides attestations are mandatory to earn a PI Score. If enrolled in CQM measures, data sign-off is mandatory.
Error in NPI	No	Submission Failed	Submission was attempted but failed due to TIN/NPI mismatch. Please raise a support ticket on the Success Community with the correct TIN/NPI information.

 

 

Submission Status field

 

The Submission Status field on the Clinician Report Card indicates whether athenahealth will submit your data based on the composite score and eligibility status. This field also allows you to review any pending actions required for submission (click Pending Action for more information about the actions you need to take).

Examples of pending actions include a required SRA sign-off or any MIPS PI attestations.

Note: For more information about submission requirements, see the MIPS Submission Guide on the Success Community.

 

Using the CMS API to connect with QPP, athenahealth retrieves your eligibility status as it relates to submission. If your eligibility check passes and your composite score check passes, athenahealth can submit your MIPS data for you. Your submission status would be Processing.

 

The submission statuses are: Processing, Pending Action, Submitted, Submission Failed, and Requirements Unmet.

Note: The Submission ID field is the QPP submission ID number generated by CMS when your data was submitted.

 

 

TIN used for measure submission

 

The Clinician Report Card shows you the tax identification number (TIN) used to submit your data. If a TIN override was applied, the report card indicates that the TIN override rules set up for Medicare on the Payer Enrollment page were used.

 

Clinicians and TINs sometimes bill under different TINs, depending on the payer, clinician, and department on a claim (an individual clinician may bill under their SSN). A TIN override means that a claim is submitted using a TIN other than the one specified for the medical group on the Medical Groups page (Federal ID field). TIN overrides are set up on the Payer Enrollment page.

 

The MIPS quality program looks for TIN overrides established when the payer is Medicare. You can set different types of overrides by adding various parameters. For example, you can create an override for TIN X with a Medicare payer override, so that any time a claim originating from TIN X is billed to Medicare, the overriding TIN is used on the claim instead.

Note: If you have any questions about TIN associations with clinicians attesting for MIPS, contact your Customer Success Manager.

 

Measure Performance view

 

To access the Measure Performance view, click the Performance menu on the MIPS Dashboard and then select Measure Performance.

The MIPS performance data helps clinicians and practice managers understand how their measure performance translates into overall success in the MIPS program. You can use the Measure Performance view to:

• View a complete list of your eligible clinicians' enrolled measures by MIPS measure category.
• Review and track your practice's measure-level performance.
• Compare your data against the average performance data of all clinicians in athenaOne who participate in the MIPS measure.
• For each clinician, verify whether the security risk analysis (SRA) is satisfied or not satisfied.
• For each clinician, verify whether public health registry (PHR) measures are satisfied or not satisfied. If a PHR measure is met by an exclusion, the measure name displays the specific exclusion with a status of "Satisfied." If more than one registry of the same type is included, the measure name is appended with "Multi."

You can sort data by any column title (click the arrow next to the column name). You can also filter data by category, clinician, and TIN.

Administration view

 

To access the Administration view, click Administration at the top of the MIPS Dashboard.

Test patients are patient records created strictly for testing purposes and do not represent a real person's chart. To remain compliant with government regulations for quality programs, make sure that you report and submit data for real patients only.

Note: In accordance with CMS and other quality program sponsors, inactive patients are included in athenahealth certified eCQMs and in quality program submission data on the MIPS Dashboard, the Pay for Performance Dashboard, the eCQM Data page, the Quality Management Reporting page, and in UDS reports.

You can use the Test Patients Identification page to find test patients and mark dummy patients as test patients. Use this page to make sure that test patients are not included in quality reporting when you create test claims, encounters, problems, or diagnoses within the test patient chart.

Note: Patients marked as test patients on the Test Patients Identification page are not included in quality program submission data on the MIPS Dashboard, the Pay for Performance Dashboard, the eCQM Data page, the Quality Management Reporting page, or in UDS reports. (Quality measures appear on the Quality tab of the test patient's chart for testing purposes only.)