Avoid MIPS Slips: What You Don’t Know Can Hurt You

The Merit-based Incentive Payment System (MIPS) can evoke a range of feelings in medical providers.

Designed to incentivize quality and cost-efficient healthcare, MIPS ties Medicare payments to clinical performance in key categories, including the quality of care delivered, efforts to improve care, and how technology is used in the practice. 

For practices that manage to stay on top of the program rules and requirements, good performance can lead to better patient outcomes as well as positive financial rewards. The maximum MIPS reimbursement for Medicare Part B claims is 9% in 2025. (Conversely, the maximum penalty for poor performance is -9%.)

But keeping up with the program’s reporting timelines and frequent changes is no simple matter. Each year brings new updates to the rules, scoring, and measure requirements, which can make it tough to know exactly what has changed and what to focus on. 

And it’s important to remember that the onus for understanding and complying with MIPS requirements falls on practices. The Centers for Medicare & Medicaid Services (CMS) does not grant leniency for ignorance or misinterpretations of the rules. 

For these reasons, many practices choose to engage with an outside advisory service for specialized assistance in keeping abreast of evolving program details and complying in the most effective way to secure an optimum outcome.

Regardless of how your practice manages MIPS, the closing quarter of the year brings focus on several program aspects and critical deadlines. Being aware of and responding to these appropriately can have significant implications on your MIPS status.

Do you know your score?

An important place to start in any program assessment is the current MIPS score. Practices should track it throughout the year, and understand how it relates to practice benchmarks.

When the practice submission module is set up, it should list the score. Knowing your score is fundamental to understanding what’s working and what improvements could be made. For instance, a MIPS score might indicate the need to take corrective actions or submit mapping refinements.

What’s your eligibility?

Every year, CMS releases two snapshots that determine a clinician’s eligibility. The first snapshot is the preliminary eligibility determination and the 2nd is the final eligibility determination. 

The 2025 final eligibility will be released in November 2025 (at the same time, preliminary eligibility for the 2026 performance year will be released).

1st Snapshot:

Date range: 10/1/2023 – 9/30/2024
Eligibility released 11/2024

2nd Snapshot (1st 2026 Snapshot released as well):

Date range: 10/1/2024 – 9/30/2025
Eligibility released 11/2025

An individual clinician’s MIPS eligibility is based on the combination of both the clinician’s National Provider Identification (NPI) and the practice tax identification number (TIN) data. The low-volume threshold for eligibility is $90,000 of Medicare Part B allowable charges, 200 Medicare Part B patients, and 200 covered professional services to Medicare Part B patients.

To check a clinician’s eligibility for the Quality Payments Program (QPP), visit https://qpp.cms.gov/participation-lookup and enter the NPI.

Have you added or changed practices?  

With the prevalence of practice mergers in healthcare, and practitioners affiliated with more than one practice, it’s important to be aware of the implications of changes. It’s a common misconception that a score from a former practice won’t follow you to a new practice. Your MIPS payment adjustment can follow you at your new practice (but doesn’t always).

There are two common approaches to TIN switch. The first is a uniform start date for all clinicians to switch to billing under the new TIN; in essence, a “clean break.” The other approach is on an individual basis, as the payer is set up; in effect, a staggered switch. 

The difference in approach can have implications. Some registries have restrictions or limitations in their acceptance of staggered switches. In which case, it may be necessary to exclude certain date ranges. Practices must meet the data completeness threshold of 75% per quality measure, so it’s important to plan ahead. Practices may also need to determine if they need to report for the legacy TIN. 

Do you need a mapping refinement or new improvement activity?

It’s important to monitor scores and benchmarks throughout the year, as well as program deadlines, to determine if corrective actions are needed and ensure they can be executed in a timely fashion. 

For example, auditing MIPS performance data is a useful strategy for submitting Quality category mapping refinements and identifying important documentation areas to improve upon. Each MIPS registry has their own Quality category mapping refinement, so it’s important to be mindful and plan data audits accordingly.

Similarly, a number of improvement activities (IA) were removed in 2025, including the popular 24/7 access IA. Some practices may be in a position of needing to select a new activity. It’s important to note, however, that each improvement activity must be performed for 90 continuous days during the performance year. To be counted toward 2025 performance year, an IA activity would need to have started by October 3.

Are you tracking the 2026 final rule release?

The final rule for the 2026 MIPS program is expected to be released in November. In addition to 2026 changes, some proposed changes could retroactively impact 2025, so monitor the release and be prepared to take appropriate action.

Additionally, the 2025 submission deadline is March 31, 2026, so practices should be lining up documentation for timely submission of 2025 data.

Position your practice for MIPS success

With MIPS, change is one constant you can count on. It’s critical to stay on top of program revisions, as well as ongoing deadlines and snapshot release dates.

Take advantage of available resources to keep abreast of evolving rules and requirements and to learn strategies for improving performance. In addition to CMS, many registries and EHR vendors offer webinars to share information on releases, program changes, and deadlines. Contact your registry or EHR for more information.

With the complexity of MIPS, it’s not surprising that many practices find it worthwhile to engage specialized services to facilitate their participation. However you choose to manage your MIPS journey, investing the effort to avoid unpleasant surprises and maximize your MIPS return can be a valuable business win.