Yes, You Do Have to Comply With a MIPS Audit Request
By David Doolittle


Remember when the Texas Medical Association first told you in June to be on the lookout for a Merit-based Incentive Payment System (MIPS) audit request for the 2017 and/or 2018 performance years? Remember that we told you the Centers for Medicare & Medicaid Services (CMS) might take further action if you did not provide the requested information? 

But then there was confusion in late July when a national physician publication reported that compliance with MIPS data validation and audit requests is not mandatory and non-punitive. 

Puzzled by this information, TMA sprung into action to make sure Texas physicians had the facts and wouldn’t get penalized if they didn’t comply. 

Well, TMA finally received clarification from CMS: Compliance is indeed mandatory and there are possible punishments for noncompliance.  

“MIPS audit requests are required to be responded to, per our regulations and policies” and “there are no exceptions or appeals for an audit request,” Timothy Jackson, CMS lead for MIPS data validation and audits told TMA, citing CFR §414.1390 as the federal code outlining the process. 

In addition, the CMS Quality Payment Program (QPP) Service Center reports: 

  • Data validation is designed to be educational and to confirm MIPS participants’ understanding of measures and activities;
  • Audits are designed to confirm MIPS participants’ compliance with selected measures and activities;
  • Noncompliance with data validation and audits could result in further education, payment adjustments, and/or future evaluations; and
  • CMS will assess payment adjustment recoupments on a case-by-case basis according to program policies and the Medicare Claims Processing Manual. 

If you are selected for an audit, the request will not come directly from CMS. Instead, it will come from Guidehouse, which is conducting MIPS data validation and audits on behalf of CMS. Letters will be sent via email or by certified mail (see sample template). 

Note that you must submit all requested data within 45 calendar days. If you’re unable to meet this requirement, you may request and use an alternate timeframe that is agreed to by Guidehouse and your practice. 

For questions about the process, contact your assigned auditor, whose contact information will be in the body of the email and/or letter from Guidehouse; or contact the QPP Service Center at (866) 288-8292 or 

For more information, refer to CMS’ fact sheet and the 2017 and 2018 (zip files) criteria used to validate and audit data submitted for each MIPS performance category. 

As always, visit the TMA MACRA Resource Center to stay up to date on all things QPP.

Last Updated On

August 14, 2019

Originally Published On

August 14, 2019

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