MIPS adjusts your Medicare payments up or down based on reported performance, applied two years after the performance year. Eligibility turns on low-volume thresholds, so many small practices are excluded — but being excluded is something to confirm rather than assume.
The most expensive thing about MIPS is how quietly it works. Nothing happens in the performance year. The consequence arrives two years later as a percentage taken off every Medicare payment, by which point nobody connects the two.
First, find out if it applies
Eligibility turns on a low-volume threshold measured on Medicare allowed charges, the number of beneficiaries seen, and the number of covered services provided. Fall below it and you are excluded entirely.
Many small practices are excluded, which is good news and worth confirming rather than assuming — status changes as volume changes, and an exclusion in one year is not a permanent condition.
The lookup is the first step
CMS publishes a participation status tool that takes an NPI and returns your status for the year. It takes a minute and it settles the question definitively.
Checking it annually is the entire compliance obligation for a practice that turns out to be excluded.
What happens if you are eligible and do nothing
The maximum negative adjustment. Not a warning, not a partial reduction — reporting nothing produces the worst score and the full penalty.
That is the specific failure worth avoiding, because a minimal good-faith submission scores far better than silence.
The categories
Quality, promoting interoperability, improvement activities and cost, weighted differently and adjusted for practice characteristics. Small practices frequently have categories reweighted, which changes the strategy considerably.
You do not need to excel across all of them. You need a coherent submission that scores above the performance threshold.
Choosing measures
Pick measures your practice already performs well on and can extract from your existing systems. A measure that requires new workflow to capture is a measure you will fail to report accurately.
Data extraction is usually the constraint rather than clinical performance.
Reporting mechanisms
Through your EHR, a qualified registry, a QCDR, or claims for some measure types depending on practice size. The mechanism affects which measures are available and how the data reaches CMS.
Most practices report through whatever their EHR vendor supports, which makes the vendor conversation part of the planning rather than an afterthought.
The two-year lag
Because the adjustment lands two years out, the practice feeling it is frequently not the practice that made the decision — partners change, billing companies change, and the reduction appears as an unexplained drop in Medicare payments.
If your Medicare payments look light and nothing else explains it, MIPS from two years ago is worth checking.
Small practice provisions
Bonus points, reduced requirements and category reweighting exist specifically for small practices. They meaningfully change what a good submission looks like.
A practice that assumes MIPS was designed for large groups and gives up is leaving those provisions unused.
Common questions
- Do I have to report MIPS?
- Only if you exceed the low-volume threshold on Medicare charges, patients and services. Below it you are excluded, and CMS publishes a lookup to check your status.
- What happens if I am eligible and do not report?
- You receive the maximum negative payment adjustment, applied to every Medicare claim two years later. Doing nothing is the worst available outcome.
- When does the adjustment hit?
- Two years after the performance year, which is why practices frequently connect the reduction to the wrong cause when it appears.
- How do I check my eligibility?
- Through the CMS Quality Payment Program lookup using your NPI. Status can change year to year as your volume changes.
- Can a small practice score well?
- Yes. Small practice bonuses and reduced reporting requirements exist, and a modest, well-chosen set of measures frequently outperforms an unfocused effort.
Denials Piling Up?
We handle the revenue cycle end to end — coding by certified coders, claim submission, denial management and appeals, and A/R follow-up, with six reported numbers every month.