Medicare payment adjustments are on the line for healthcare practices reporting under MIPS in 2026, and the downside is the part worth planning around. A practice that fails to clear the performance threshold faces a negative adjustment of up to 9% applied to every Medicare Part B payment for a full year. The upside is not symmetrical: positive adjustments are scaled for budget neutrality and have landed well below 9% in every year of the program, so the penalty is the number to build your plan around. With the Merit-based Incentive Payment System (MIPS) now in its tenth performance year, understanding how it affects your billing operations is no longer optional.
Talk to our billing experts about MIPS compliance for your practice.
MIPS is part of the broader MACRA framework that replaced the old Medicare payment formula. Whether you run a solo practice or manage a multi-provider group, MIPS performance directly shapes your Medicare reimbursements. This guide breaks down what changed for 2026, how each performance category works, and what your practice can do right now to stay compliant and protect your revenue.
What Is MACRA and How Does It Affect Medical Billing?
MACRA (the Medicare Access and CHIP Reauthorization Act) is federal legislation signed into law in 2015. It replaced the old Sustainable Growth Rate (SGR) formula that had governed Medicare physician payments for decades. Instead of across-the-board payment adjustments, MACRA introduced a value-based system that ties reimbursement to quality and performance.
MACRA created two pathways for Medicare clinicians:
- MIPS (Merit-based Incentive Payment System): Evaluates clinicians across four performance categories and adjusts their Medicare Part B payments based on a composite score.
- Advanced Alternative Payment Models (APMs): Offers a separate track for clinicians participating in qualifying risk-based payment arrangements, such as accountable care organizations (ACOs).
For most medical practices, MIPS is the relevant pathway. It directly impacts how much Medicare pays for services, which means it affects your revenue cycle management from claim submission through final reimbursement. The program measures how well you deliver care, manage costs, use health IT, and participate in practice improvement, then adjusts future payments accordingly.
What Is MIPS in Medical Billing?
MIPS is a Medicare quality reporting program that scores clinicians on a 0-to-100 scale and adjusts their Medicare Part B reimbursements based on that score. Practices that score above the performance threshold earn a payment bonus, while those falling below face a penalty applied to all covered professional services billed to Medicare. For the 2026 performance year, those payment adjustments will apply to reimbursements starting January 1, 2028.
From a billing perspective, MIPS touches nearly every part of your operations. Accurate medical coding feeds into quality measure calculations. Claims data determines your Cost category score without any separate submission. And incomplete reporting or missed deadlines can trigger automatic penalties that reduce every Medicare payment your practice receives for an entire year.
Who Needs to Report MIPS in 2026?
MIPS eligibility is determined by Medicare claims volume. Clinicians must exceed all three of the following thresholds during both determination periods to be MIPS-eligible:
- Bill more than $90,000 in Medicare Part B allowed charges
- Provide services to more than 200 Medicare Part B beneficiaries
- Furnish more than 200 covered professional services
The determination periods for 2026 are October 1, 2024 through September 30, 2025 (Segment 1) and October 1, 2025 through September 30, 2026 (Segment 2). If a clinician falls below any one of these thresholds in either segment, they are exempt from MIPS for the 2026 performance year.
Clinicians who are newly enrolled in Medicare or who qualify as participants in Advanced APMs are also exempt. You can verify your eligibility status through the CMS Quality Payment Program (QPP) portal.
2026 MIPS Performance Categories and Weights
Your MIPS final score comes from four performance categories, each carrying a specific weight. CMS did not change the category weights for 2026, keeping them consistent with the prior year:
| Performance Category | Weight | What It Measures |
|---|---|---|
| Quality | 30% | Clinical outcomes and process measures across your patient population |
| Cost | 30% | Medicare spending attributed to your patients, calculated from claims data |
| Promoting Interoperability (PI) | 25% | Meaningful use of certified EHR technology for health information exchange |
| Improvement Activities (IA) | 15% | Participation in clinical practice improvement activities |
Quality Category (30%)
The Quality category requires practices to report on six measures, including at least one outcome or high-priority measure. Data collection runs the full calendar year (January 1 through December 31, 2026). For 2026, CMS lists 190 total measures available, with 5 new measures added, 10 removed, and 30 updated from the prior year.
Measure selection matters. Choosing measures where your practice performs well relative to national benchmarks can significantly boost your score. This is where billing data analysis becomes valuable, as your claims history reveals which measures align with your patient mix and coding patterns.
Cost Category (30%)
The Cost category is unique because it requires no separate data submission. CMS calculates your score entirely from Medicare claims data, evaluating 35 cost measures that look at how efficiently your attributed patients are treated. The Total Per Capita Cost (TPCC) measure received an update for 2026, and CMS introduced a new two-year informational feedback period before any new cost measures are scored.
Because this category depends on claims, the accuracy of your billing directly affects your Cost score. Complete documentation, accurate coding, and proper risk adjustment through Medicare billing guidelines can all influence how CMS evaluates your cost efficiency.
Promoting Interoperability (25%)
This category measures how effectively your practice uses EHR technology to share health information. The minimum reporting period is 180 continuous days, meaning the last day to start your PI performance period in 2026 is July 5. New for 2026, CMS introduced an optional bonus measure related to TEFCA (Trusted Exchange Framework and Common Agreement) participation and updated the SAFER Guides attestation requirements.
Small practices (15 or fewer clinicians) receive automatic PI reweighting. If a small practice does not submit PI data, the Quality category weight increases to 40% and Improvement Activities increases to 30%, with Cost remaining at 30%.
Improvement Activities (15%)
Improvement Activities require the least effort but still carry meaningful weight. Large practices must complete two activities for at least 90 continuous days each. Small practices and MVP reporters need only one. For 2026, CMS offers 99 activities (3 new, 8 removed, 7 modified) and replaced the Achieving Health Equity subcategory with Advancing Health and Wellness. CMS’s 2026 Improvement Activities Quick Start Guide describes the inventory as “almost 100 activities.”
Get a free consultation to see how MIPS reporting affects your practice revenue.
How Do MIPS Payment Adjustments Work?
MIPS operates on a two-year lag. Your 2026 performance determines the payment adjustments applied to your Medicare Part B reimbursements beginning January 1, 2028. Here is how the scoring breaks down:
| Final Score Range | 2028 Payment Impact |
|---|---|
| 0 to 18.75 points | Maximum penalty: -9% on all Medicare Part B payments |
| 18.76 to 74.99 points | Negative adjustment on a sliding scale (between -9% and 0%) |
| 75 points (threshold) | Neutral: no adjustment |
| 75.01 to 100 points | Positive adjustment (subject to budget neutrality scaling) |
The performance threshold stays locked at 75 points through the 2028 performance period. That means practices need a strong showing across all four categories to avoid penalties. A practice scoring below 75 will see every Medicare claim paid at a reduced rate for all of 2028.
For context, consider a medical practice that collects $800,000 annually in Medicare Part B reimbursements. A -9% penalty would reduce those payments by $72,000 over the year. On the other hand, scoring well above 75 could yield a positive adjustment, though the exact bonus percentage depends on the budget neutrality scaling factor CMS applies.
What Changed for the 2026 MIPS Performance Year?
While CMS kept the overall MIPS structure stable for 2026, several updates affect reporting and compliance:
- Quality measures: 5 new measures added, 10 removed, and 30 updated across the 190-measure library
- MIPS Value Pathways (MVPs): 6 new MVPs added (total now 27), covering specialties like diagnostic radiology, podiatry, and vascular surgery
- Improvement Activities: 3 new activities, 8 removed, 7 modified, and a new Advancing Health and Wellness subcategory replacing Achieving Health Equity
- Promoting Interoperability: Optional TEFCA bonus measure introduced and updated SAFER Guides attestation
- Cost measures: No new measures, but the TPCC measure was updated and CMS established a two-year informational feedback period for future new cost measures
- Multispecialty group MVP restriction: Groups with multiple specialties can no longer register at the group level for MVPs; they must report at the individual, subgroup, or APM Entity level (small multispecialty practices are exempt)
- Performance threshold: Confirmed at 75 points through 2028/2030
The biggest takeaway is the continued expansion of medical billing technology requirements and CMS’s incremental push toward MVPs as the future of MIPS reporting.
MIPS Value Pathways: What Your Practice Should Know
MIPS Value Pathways (MVPs) are specialty-specific reporting frameworks that CMS has been expanding since 2023. For 2026, there are 27 MVPs available, up from 21 in 2025. The new additions cover diagnostic radiology, interventional radiology, neuropsychology, pathology, podiatry, and vascular surgery.
MVP reporting remains optional for 2026, but that is changing, and the signal is now much firmer than it was. In the CY 2027 Physician Fee Schedule proposed rule, released July 14, 2026 and published in the Federal Register on July 16, CMS formally proposed to sunset traditional MIPS after the CY 2028 performance period and make MVPs the primary reporting pathway for clinicians outside MIPS APMs. That is a proposal, not final policy, but practices that have been putting off an MVP evaluation now have a date to plan against. Practices considering the switch should know that MVPs require reporting four quality measures, one improvement activity, PI data, and a population health measure, with cost calculated from claims by CMS.
If your group plans to report an MVP, registration opened April 1, 2026 and is still open — the deadline is 8 p.m. ET on November 30, 2026, so there is time to act. The CAHPS for MIPS Survey registration window has already closed for this performance year; it ran April 1 to June 30, 2026, and practices that missed it will need to plan for the 2027 performance year instead.
2026 MIPS Reporting Timeline and Deadlines
Staying on top of deadlines is one of the simplest ways to protect your MIPS score. Here are the key dates for the 2026 performance year:
| Date | Action Required |
|---|---|
| January 1, 2026 | Performance year begins; quality data collection starts |
| April 1, 2026 | MVP registration opens |
| April 1 to June 30, 2026 | CAHPS for MIPS Survey registration window |
| July 5, 2026 | Last day to begin 180-day PI performance period |
| October 3, 2026 | Last day to start 90-day Improvement Activities period |
| November 30, 2026 (8 PM ET) | MVP registration deadline |
| December 31, 2026 | Performance year ends; hardship exception deadline |
| January 2, 2027 | Data submission window opens |
| March 31, 2027 (8 PM ET) | Data submission deadline |
| January 1, 2028 | Payment adjustments based on 2026 scores take effect |
How a Medical Billing Partner Helps With MIPS Compliance
Managing MIPS reporting alongside daily billing operations stretches most practice teams thin. A dedicated medical billing service brings specialized knowledge that can directly improve your MIPS performance in several ways:
Measure selection based on claims analysis. Your billing partner can review your historical claims data to identify which quality measures best match your patient population and coding patterns. Selecting the right measures is often the difference between a score of 60 and a score of 85.
Quarterly performance tracking. Rather than waiting until year-end to discover problems, an experienced billing team monitors your performance metrics throughout the year. This allows time to adjust documentation practices, coding specificity, or measure strategies mid-course.
Cost category optimization through billing accuracy. Since CMS calculates your Cost score from claims data alone, the completeness and accuracy of your billing directly influences this 30% portion of your MIPS score. Proper HCC (Hierarchical Condition Category) coding, accurate diagnosis documentation, and clean claims help ensure CMS attributes costs fairly to your practice.
Pre-submission data validation. Before the March 31 deadline, your billing team reviews all reported data for completeness, accuracy, and compliance with CMS specifications. This step catches errors that could trigger data rejection or score reductions.
Exception and hardship applications. When circumstances warrant (natural disasters, EHR transitions, small practice status), a knowledgeable billing partner can prepare and submit the appropriate hardship exception applications before the December 31 deadline.
Working with a billing company that understands both the regulatory requirements and the day-to-day reality of practice management allows your clinical team to focus on patient care while maintaining strong MIPS performance.
Contact AMS Solutions to learn how we handle MIPS reporting for practices like yours.
Common MIPS Mistakes That Hurt Your Score
After nearly a decade of MIPS, some errors still appear consistently across practices:
- Choosing the wrong measures. Selecting measures where your practice falls below national benchmarks guarantees a low Quality score. Review benchmark data before committing to a measure set.
- Incomplete data submission. Reporting on fewer than six quality measures, or failing to meet data completeness thresholds, can result in points left on the table or outright score reductions.
- Missing the PI start date. If you begin your PI reporting period after July 5, you cannot reach the required 180 continuous days before year-end.
- Ignoring the Cost category. Because CMS calculates Cost from claims, practices sometimes assume they have no control over it. But coding accuracy, documentation completeness, and risk adjustment all affect how costs are attributed.
- Waiting until year-end to review data. Quarterly check-ins give you time to course-correct. Practices that only look at their data in January often discover gaps too late to fix.
- Skipping Improvement Activities. This is the easiest category to score points in. Missing it means giving up 15% of your total score for activities that require only 90 days of effort.
How Do Small Practices Handle MIPS Reporting?
Small practices (15 or fewer eligible clinicians) receive several accommodations under MIPS that larger groups do not:
- Automatic PI reweighting: If a small practice does not submit PI data, the category weight drops to 0%. Quality increases to 40% and Improvement Activities to 30%, with Cost staying at 30%.
- Reduced Improvement Activities requirement: Only one activity for 90 continuous days (vs. two for large practices).
- MVP group registration flexibility: Small multispecialty practices can still register at the group level for MVPs, unlike larger multispecialty groups.
These accommodations recognize the resource constraints small practices face. However, they also mean the Quality and Cost categories carry even more weight in your final score. Working with a billing team that understands these challenges becomes especially important for smaller practices where every point matters.
Frequently Asked Questions
What is MIPS in medical billing?
MIPS (Merit-based Incentive Payment System) is a Medicare quality reporting program created under MACRA. It evaluates healthcare clinicians across four performance categories and adjusts their Medicare Part B payments based on a composite score. For the 2026 performance year, the resulting payment adjustments apply to reimbursements beginning January 1, 2028.
What score do I need to avoid a MIPS penalty in 2026?
You need a final score of at least 75 out of 100 points to avoid a negative payment adjustment. Scoring below 75 results in a penalty of up to -9% on your 2028 Medicare Part B reimbursements. The 75-point threshold has been confirmed through the 2028 performance period.
What are the MIPS performance category weights for 2026?
The 2026 MIPS category weights are Quality at 30%, Cost at 30%, Promoting Interoperability at 25%, and Improvement Activities at 15%. CMS did not change these weights from 2025. Small practices that do not submit PI data see Quality reweighted to 40% and Improvement Activities to 30%.
What happens if I do not submit MIPS data?
Failing to report MIPS data results in the maximum -9% penalty applied to your Medicare Part B payments for 2028. Even partial reporting is better than no reporting, as submitting data on at least one measure avoids the full automatic penalty.
When is the MIPS data submission deadline for 2026?
The data submission window opens January 2, 2027, and closes March 31, 2027, at 8 PM Eastern Time. Quality data must be collected for the full calendar year (January 1 through December 31, 2026), while PI requires a minimum 180-day period and Improvement Activities require 90 continuous days.
How does MIPS affect medical billing operations?
MIPS affects billing in multiple ways. The Cost category (30% of your score) is calculated entirely from claims data, making billing accuracy a direct factor. Quality measure reporting depends on proper coding and documentation. And the financial consequences (up to 9% payment adjustment) flow through every Medicare claim your practice submits.
Protect Your Revenue With Proactive MIPS Management
MIPS is not going away. With performance thresholds locked at 75 points and payment adjustments reaching 9%, the program’s impact on medical billing grows each year. The practices that perform best are those that treat MIPS as an ongoing part of their billing operations rather than a year-end compliance exercise.
Whether you need help selecting the right quality measures, monitoring your Cost category performance, or validating your data before submission, having an experienced billing partner in your corner makes a measurable difference. AMS Solutions has helped medical practices across the country manage their revenue cycles and practice operations since 1992. Call us at 866-973-2221 or contact us online to discuss how we can help your practice stay ahead of MIPS requirements in 2026 and beyond.
