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Guide to MIPS Reports

MIPS Introduction

Purpose: To show the provider his current performance and to create a strategic plan (selection of targeted quality measures that will both yield the highest score and that we are likley to use to attest).


MIPS Monthly Review

Purpose: Shows how the practice is doing relative to the strategic plan already created. It contains the following slides:

  • Performance Gauge: Current Performance & Max Potential
  • MIPS Category Report Card
  • Measures with Most to Gain
  • Measure performance gauges for all QM performing below the 5th decile (Measure Gauges link)
  • Action plan for one of the poorly performing measures

During the review call with the provider, good habits are reinforced and improvement plan is decided upon if there are underperforming measures. A single measure is also selected for improvement, to be tracked via the MIPS Week Analysis. This decision is to be made by the provider and staff with guidance from WRS. (IE. Don't let them pick a measure that shows little promise of growth/improvement).

Purpose: To identify patients who fall into each category of missed opportunities to be listed for the practice to review with their staff to identify any non-data influencers on the workflow.

This report is run 1 week after the Monthly Review call with the provider.


Follow the MIPS Calculation and Presentation Tools links below for work instructions on how to run and create reports: