In this episode, Dr. Dan Mingle answers a question from John, a community health system leader facing a new and difficult MIPS reality. In his answers for John, Dr. Mingle provides a detailed explanation of the steps required for any MIPS-eligible provider or organization to improve their MIPS scores.

Click play on the video below to access this episode, or scroll down for the written summary.

How to Improve Your MIPS Scores

John says: “We are a community health system and have been using eCQMs through our EHR and reliably getting a small positive MIPS adjustment. That is, until this most recent reporting period, when we ended up in the penalty range. How do you recommend we get ourselves back to a positive number again?”

Great question, John. I think you are in good company. A lot of good organizations are finding themselves with negative MIPS adjustments.

MIPS has been ramping up since its onset in 2017, gradually reducing opportunities for bonus points and bringing all performance categories up to their most demanding.

A lot of the “phase in” dynamics were actually hidden by COVID-related forgiveness for four years of the pandemic. The phase-in continued invisibly behind the scenes and MIPS returned at its full ramped-up dynamics when the pandemic officially ended.

2024 was the first full year without substantial pandemic forgiveness. 2026 will be the first year that we experience the full weight of post-pandemic adjustments to our Medicare payments.

Understanding MIPS Scoring

The first point to realize is that no matter how well you do, the system is designed to give roughly half of participants a negative adjustment and give the money retained from those negative adjustments to the providers in the positive adjustment range. There are still some oddities in the math of the grading curve, but conceptually that is how it is intended to work. Half of us will experience negative adjustments that will fund the positive adjustments experienced by the other half.

You not only have to do well on all four performance categories, but you also have to be in the upper 50th percentile of performance when compared to your peers. You cannot afford to neglect any performance category.

The Path to 100 Points

A perfect MIPS score is 100. Contributing to that 100 points are four performance categories:

• 30 points can come from a perfect Quality score
• 30 points can come from a perfect Cost score
• 25 points from a perfect Promoting Interoperability score.
• 15 points from a perfect Improvement Activities score.

There are a lot of special exceptions to these basic rules. But, overall, this is how the program works, and mastering your knowledge of the basics should help you push toward a positive adjustment more reliably every year.

Medicare has set a target of 75 total points to be the “performance threshold.” Below 75 earns a negative MIPS adjustment, and above 75 earns a positive MIPS adjustment.

A total miss in either Cost or Quality gets you out of the running for a positive adjustment. A total miss in Promoting Interoperability means you can, at best, have a neutral adjustment. Points from Improvement Activities should be a solid foundation on which you can build the rest of your submission.

I’ll divide the rest of my remarks into a section for each of the four performance categories.

Improvement Activities (IA)

Let’s consider Practice Improvement first.

It should be a reliable 15 points. The principal cost of the Improvement Activities (IA) category is the opportunity cost. Your providers need to put in the requisite time and effort. There should be no reason not to collect 15 points for this category.

It’s even easier in 2025 than it has been previously. Starting in 2025, all activities have the same weight. A group practice with no special status needs just two activities to get a full score.

There are a lot of activities to choose from. The key is to find two that align reasonably well with your goals. To earn points in Improvement Activities:

• Half of your provider staff must be engaged with each project to get credit.
• Each project must be active for at least 90 days in the performance year for each provider to be counted.

The list and specifications for Improvement Activities are available on the Quality Payment Program website. The specifications will describe exactly what needs to be done to qualify and exactly what records need to be kept to prove involvement.

It does not need to be time-consuming, but providers do need to be involved. Particular projects might involve the purchase and implementation of software or equipment, the printing of new forms, the hiring of staff, or training existing staff to operate the new process.

Promoting Interoperability (PI)

If you want to score well in MIPS, you cannot neglect the “Promoting Interoperability” (PI) category.

There are a number of special circumstances that render this performance category irrelevant. If so, the points will be redistributed to the remaining performance categories, making each of them much more important.

To earn points in this category:

• You have to use an EHR.
• It has to have up-to-date certification as specified by the Office of the National Coordinator of Health IT.
• And you need to be able to show that you are using it in certain ways.

This can have a significant price tag to license software, acquire and maintain the necessary hardware, train users and maintain skills, and implement associated functions.

The functional requirements include:

• Electronic Prescribing
• Query of your State’s Prescription Drug Monitoring Program
• Exchange Electronic Health Records with clinical partners:
  • Receive when getting referrals
  • Send when making referrals
  • A few options to make this work:
    • Direct exchange
    • Use of regional Health Information Exchange (HIE)
• Provide patients access to their health information:
  • Most organizations do this with a patient portal
  • A patient portal might come with your EHR or be an independent add-on
  • There are expenses related to licensing, implementation, maintenance, and operation
• Exchange data with your:
  • State Immunization Registry
  • State Health Department for mandatory case reporting
• And there are a number of attestations related to CEHRT use, restrictions on access, and security

Most deficiencies in your proof of use result in a 0 score in the category. There are limited exclusions available that are usually temporary and result in redistribution of the available points.

Cost

You probably have the least immediate input into this category. And it counts for 30% of your total MIPS score.

A loss of or forfeiture of all 30 points makes it impossible to be above the 75-point performance threshold to be in the positive incentive range.

The cost profile in your system is deeply rooted in training, local traditions and expectations, and local peer pressure. It’s hard to change even if you know what you need to change.

It’s hard to check this frequently to monitor the results of your efforts. You can’t do it with your own claims. You have to do it from an insurer-sourced comprehensive claims data set.

Two techniques quickly come to mind to address your Cost scoring:

• One is the generic, “I expect these techniques to reduce healthcare costs.”
  • You can make some meaningful changes on common-sense type decisions even if you cannot be guided by ready access to data.
• The second is strategic decisions on Cost participation.
  • The one thing I have in mind is that it might be useful for you to choose a MIPS Value Pathway (MVP) option to limit your Cost liability.

In striving to improve your Cost performance, be guided, first, by your historic Cost scores.

Medicare has access to its own comprehensive sets of claims and calculates annually its own cost measures. Most of us have access to those annual measurements through our feedback reports from Medicare.

Most of us deal with enough volume that there is some statistical stability in our Cost profiles from year to year. They usually don’t move much without deliberate effort or a major event of some kind.

Look at your Cost scoring in your feedback reports from CMS for the last few years. It’s a good bet you will see stability. If your Cost profile is naturally comparatively good, you can put more of your attention elsewhere.

If your profile isn’t good, launch an effort to bring it down, but recognize in the short run, it’s likely to be more achievable to maximize your MIPS scores on the other three performance categories.

I’ve talked more specifically about containing costs in past episodes, and I’ll do it again in the future. It’s not my intent today to get too far into the weeds on this topic.

Be guided by the literature. I particularly like the work behind the Dartmouth Atlas, which deals primarily with unexplained differences in healthcare cost from region to region.

Also think about participating in MIPS Value Pathways (MVPs).

In the 2025 performance year, you can still use an MVP to score your entire multispecialty practice. That option won’t be around indefinitely. It had been projected, initially, to expire for the 2025 performance year when, to use MVPs you would be required to divide into subgroups. But CMS did not choose to set that restriction for 2025, and it is uncertain, at this point, when they will.

In traditional MIPS, every practice is evaluated on all Cost measures for which they have adequate case minimums. In MVPs, a practice or a subgroup using that MVP is only judged on the Cost measures included with the MVP.

Choose wisely. If you are not going to score well in Cost for an MVP you are eligible to submit, the MVP won’t be a good choice for you.

Stay tuned. I’ll dig into this with more specifics and more references in a future episode. In the meantime, I’d be delighted to hear from any of you if you’ve used an approach that brought your Cost profile down for you.

Quality

John’s intent with this question was to dig into his approach to Quality, and there are a number of tools you can use to go after this.

Submission Mechanism: eCQMs vs. MIPS CQMs

You’ve been using eCQMs. If they are working well for you, it’s a solid technique. But there are a number of limitations.

Pricing is a strategic decision of your EHR vendor that can make it either easy or hard. Some EHR vendors charge aggressively for eCQM delivery; others include it in the core license. An EHR typically has to focus on a one-size-fits-all strategy. They either can’t customize per client, or it can be overly difficult to maintain.

There are third party vendors doing eCQMs applicable to multiple EHR platforms. Those independent third parties can be more customizable. But there are still limitations in eCQM production that do not limit MIPS CQM production.

There are significant weaknesses to the typical EHR’s eCQM capabilities for which MIPS CQMs are a great antidote. If you aren’t getting the quality scores you want with eCQMs, consider MIPS CQMs.

eCQM Failure Points

• Configuration and implementation issues:
  • This is about setting up the system to accept documentation of your clinical work. Sometimes choices that make sense to the users and your local EHR support team can exclude data from the eCQM engine.
    • I’ve seen templates for documentation that don’t save data where the eCQM engine can see it. Other templates that malfunction by replacing old data with new, rendering historic analysis unreliable.
    • MIPS CQMs can give you the flexibility to get the data where it lives. It can also give you enough core granular data to identify and correct configuration anomalies. MIPS CQMs are a great tool, with enough data availability, to prepare your practice for effective eCQM use.
• Training and compliance can be an issue:
  • If you’ve set things up appropriately to feed the needed data to your measurement engine, it still depends on your users following the recommended documentation workflows.
    • I have found that clinicians can find a lot of different ways to document that makes more sense to them than what you intended.
    • MIPS CQMs give you the ability to “cast a larger net” to pick up documentation that lives in more creative locations.
• Measure limitations can be a big issue:
  • There are fewer measures available as eCQMs than as MIPS CQMs.
    • The eCQM inventory for 2025 is 47.
    • There are 169 MIPS CQMs to choose from.
• “Topped out” status:
  • This is end-of-life for a quality measure and usually accompanied by a 7-point cap on available performance points. It’s hard to score above 75 to get into the positive MIPS adjustment range if you are using measures capped at, effectively, 70. Topped out status is specific to the submission mechanism. A measure that is topped out and capped in one mechanism may not be in both. With fewer measure choices in eCQMs, you may not be able to come up with six solid choices without choosing some that are topped out.
• Benchmarks:
  • Every measure has scoring benchmarks to place your score in a competitive array with those of other groups. Benchmarks are set separately by method.
  • The same measure generating the same performance rate in each eCQM and MIPS CQM might very easily give you a better score in one system than the other.

Score Improvements Through Data Validation

No measurement system is perfect. It’s easy to miss data that would improve your score. You can correct either a MIPS CQM or an eCQM submission, but it is easier to correct MIPS CQMs.

Let me inject here that I think you should validate your data every year. You can use the validation process to improve your system—ultimately to improve your readiness for eCQMs. And you can use the validation process to improve your score.

For your own use, it’s the patients in the status of “Performance Not Met” that is of most interest and importance. “Performance Met” is usually accurate.

Take, as an example, influenza vaccination. Finding a record of administration means that performance is met. Lacking data may mean that performance is not met, but it may also mean that it was not recorded, or it was not recorded in the immunization table.

I suggest you choose between ten and all of your Performance Not Met instances and cross-check by manually abstracting their medical records. When you find data in the chart that your data extraction missed, you have found “gold” with which to improve your scoring immediately and your processes in the long term.

• In the short run, you can correct your submission. If you are doing MIPS CQMs, you can submit to us a supplemental Performance Spreadsheet that can flip the switch for the affected patients from Performance Not Met to Performance Met. If you are doing eCQMs, you can correct the chart through whatever formal record correction method you follow.
• In the long run, you’ll fix your future quality submissions in one of two or a combination of both methods:
  • Identify the providers who are not documenting in a place you get data for analysis and provide remedial training.
  • Expand your extraction queries to include the additional locations you’ve identified as holding pertinent data.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

Want to learn more about the MIPS program in 2025?

As MIPS becomes more difficult, it's crucial to have a plan in place. We've made a guide that provides an overview of 2025 MIPS requirements and changes to help you and your organization find success in the 2025 Performance Year.

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