MIPS (Merit-based Incentive Payment System), a Medicare program that rewards clinicians for delivering high-quality, cost-efficient care, is by nature an evolving entity.
Much the way healthcare continually changes as new knowledge, treatments, and technologies modify past practices, MIPS is ever-changing, with program updates, revisions, and new requirements.
While these changes are well-intentioned and support value-based healthcare, they don’t necessarily make it easier for participants to keep up. Failing to keep up with the program intricacies can have unfortunate consequences for practices, including affecting compensation and reputation. To reduce the burden of tracking ongoing program changes, many medical practices elect to engage with third-party MIPS advisory services, which can facilitate compliance and free practitioners to focus on patient care.
For 2026, there are a series of MIPS updates that are important for participants to note in order to optimize their results and avoid unpleasant surprises.
Program Background and Basics
MIPS has a history of evolution, combining former programs, Physician Quality Reporting System (PQRS) and Meaningful Use (MU). Currently MIPS is structured around four performance categories, covering the quality of care delivered, efforts to improve care, how technology is used in the practice, and cost efficiency.
The program has different applicability for large and small practices. Large practices are defined as having 16 or more Medicare Part B-recognized providers and small practices 15 or less. (In cases where a practice has a provider who does not have a Medicare contract, that provider would not count toward the total.)
Practices participating in MIPS earn a score based on performance across four categories, with a minimum performance threshold of 75 points to avoid a penalty. This threshold is slated to continue through 2028 but subject to change in the future.
It’s also important to note that the timing of payment adjustment is two years after the performance year. For example, a 2026 performance score will impact a practice’s 2028 payment adjustment.
The current adjustment scale has scores above 75 earning up to a possible 9% positive payment adjustment, while scores below 75 subject to a negative adjustment of up to 9%.
The four MIPS categories and their contribution to the overall MIPS score include:
- Quality (30%) – The quality category is scored out of 60 points and functions like a report card for the medical care clinicians deliver. It assesses things such as appropriately screening for specific conditions and procedures, managing chronic conditions effectively, and keeping patients safe. MIPS allows practices to pick specific measures most relevant to their specialty.
- Promoting Interoperability (25%) – This category, scored out of 100 points, focuses on the effective use of technology to communicate with patients and other providers. It promotes patient engagement and the secure electronic exchange of health information through the use of certified electronic health record technology (CEHRT).
- Improvement Activities (15%) – This category assesses how clinicians improve the care process, enhance patient engagement, and increase access to care. Scored out of 40 points, it includes items such as patient satisfaction surveys and associated, measurable follow-up action.
- Cost (30%) – Evaluates the cost of care clinicians provide to patients. Centers for Medicare and Medicaid Services (CMS) automatically calculates this category using Medicare claims data to assess the cost of care for specific patients or episodes. Practices don’t need to submit anything extra. The category aims to ensure that patients are treated efficiently, without unnecessary tests or procedures that aren’t deemed to add value.
Determining Eligibility
It’s important to check to confirm if a practice is eligible and required to report MIPS. This can be done directly within QPP with a HARP account. Alternatively, you can enter clinician NPIs to view the eligibility requirements in the QPP Eligibility Lookup Tool.
There are three low-volume eligibility thresholds:
- $90,000+ Medicare Part B allowed charges
- 200+ Medicare Part B patients
- 200+ covered professional services to Medicare Part B patients
Note that practices can be opt-in eligible if they qualify for any one of the low-volume thresholds, and in many cases there is value to be gained by practices opting in to participate.
The first Snapshot of 2026 Eligibility has already been released for the date range October 1, 2024 to September 30, 2025.
The second Snapshot for 2026 (which also functions as the first 2027 Snapshot) will cover the date range of October 1, 2025 to September 30, 2026. It will be available in the November to December 2026 timeframe, so practices should monitor that release.
Why MIPS Performance Matters
The financial impact of MIPS performance can be significant — affecting up to a 9% increase or decrease in Medicare Part B reimbursement. But MIPS performance influences more than just financial reimbursement.
The very process of tracking MIPS measures can reveal care trends and opportunities for improvement, and can strengthen a practice’s readiness for evolving value-based care and alternative payment models. Furthermore, MIPS performance can shape a significant impact on a practice’s reputation through public reporting.
While the importance of MIPS is clear, managing it can be complex and time-consuming.
Challenges for Practices
In many small, and even large practices, people have multiple roles and responsibilities. Effectively managing the MIPS reporting requirements while keeping up with program changes can be challenging.
Some of the most common pain points with MIPS for clinicians include:
- Measure selection – Deciding on the metrics best aligned with specialty and practice
- Data accuracy – Tracking and validating performance data to minimize audit failure risk
- Complex scoring – Navigation category weighting and performance calculations
- Compliance management – Keeping up to date with regulatory requirements and changes
- Deadline management – Staying on track with key milestones, including the final submission deadline
- Time constraints – Balancing reporting demands with limited clinical and administrative time
Changes in 2026
With the scale and complexity of MIPS, the amount and specificity of changes can be daunting to process. The following is a sampling of changes to the core MIPS categories for 2026:
Quality:
- Administrative claims measures will now be scored like cost measures, with the standard deviation set to 7.5 points, and retroactively applied to the 2025 performance year (for large practices only). Scored on up to 2 administrative claims measures.
- Three ophthalmology-specialty measures removed: Measure 419: primary headache, order CT or MRI; Measure 508: adult COVID-19 vaccination status; and IRIS35: Improvement of Macular Edema in Patients with Uveitis
Promoting Interoperability:
- Electronic case reporting (eCR) measure has been suppressed and retroactively applied to 2025 (continue to report the measure though if not otherwise excluded).
- Measure suppression option has been added. Measure weighting will behave like an exclusion wherein the points are re-weighted to other measures.
- High priority SAFER has been updated to the 2025 version (was previously 2016).
- Trusted Exchange Framework and Common Agreement (TEFCA) bonus: 5 points available when participating in a TEFCA-align network via CEHRT.
- Security Risk Analysis: Additional attestation required; must implement security measures to reduce identified risks.
- (Potential in the future) Prescription Drug Monitoring Program (PDMP) – May shift to performance-based instead of attestation.
Improvement Activities:
- Health Equity measure group – Eight measures paused in mid-2025 have been officially removed.
- Removed – Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop.
- Removed – Improvements that Contribute to More Timely Communication of Test Results.
- New measure – Patient Safety in Use of Artificial Intelligence (AI).
Cost:
- Total Per Capita Cost (TPCC) measure – PA-Cs and NPs reporting under a TIN are excluded if all the other clinicians in that TIN meet the specialty exclusion criteria.
- New policy – CMS will provide a two-year informational-only feedback period for any new cost measure.
Additionally, there are a number of 2026 changes focusing on expanding MIPS Value Pathways (MVPs), a streamlined, currently voluntary reporting option. Changes include new specialty options (Radiology, Pathology, Podiatry, etc.), and streamlining quality measures into “Clinical Groupings”. The current plan is to make MVP reporting mandatory by 2029, while phasing out traditional MIPS.
Key Takeaways
While the benefits of MIPS are far-reaching, annual program changes, frequent deadlines, and complex scoring measures can make the program time-consuming and difficult to navigate.
Many practices and clinicians opt to engage with consulting or advisory services for specialized guidance and assistance. This can range from support with creating and submitting tickets or guidance on ensuring accuracy, to a hands-off outsourcing solution.
However a practice approaches MIPS, it’s important to not only track annual program changes, but continue monitoring for key dates and deadlines throughout the year. An effective MIPS strategy will help practices ensure compliance, maximize incentive payments, and improve patient outcomes.
About Renee Freyer
Renée Freyer is the Senior Manager of Clinician Services (MIPS/VBC) at Verana Health. With nearly 20 years in healthcare, Renee Freyer has seen the challenges of the Merit-based Incentive Payment System (MIPS) from multiple angles. Her experience in clinical care and operations shapes the insight that she shares through Verana Health MIPS Advisory Services.
