The Medicare Access and CHIP Reauthorization Act of 2015—MACRA— MIPS and MACRA in Medical Billing fundamentally transformed how Medicare pays physicians. It retired the Sustainable Growth Rate formula that had haunted Medicare physician payment for nearly two decades. More importantly, it created an entirely new framework for value-based reimbursement: the Quality Payment Program (QPP) .

A decade after MACRA’s enactment, the QPP is no longer a novel experiment. It is a mature regulatory program affecting more than one million clinicians and determining payment adjustments for every Medicare-participating provider in the United States. Yet for many medical billing professionals, MIPS and MACRA in Medical Billing remain sources of confusion, anxiety, and missed revenue opportunities.

This confusion is understandable. The Merit-based Incentive Payment System (MIPS) has evolved continuously since its 2017 launch. MIPS reporting requirements change annually. MIPS scoring categories are recalibrated. MIPS payment adjustment calculations grow more sophisticated. Advanced Alternative Payment Models (APMs) have multiplied while their incentive structures have shifted. And MACRA implementation continues to unfold with each subsequent Physician Fee Schedule final rule.

MIPS Value Pathways (MVPs)

The 2026 performance year represents a pivotal moment in this evolution. CMS has committed to program stability through 2028, maintaining the performance threshold at 75 points and providing predictable scoring frameworks . Yet beneath this surface stability, significant changes are underway. MIPS Value Pathways (MVPs) are expanding rapidly, signaling the eventual sunset of Traditional MIPS. Cost performance category methodologies are being refined for greater fairness. APM incentive payments are transitioning from lump-sum bonuses to differential conversion factors. And Promoting Interoperability requirements are tightening around security risk management.

This 360-degree guide provides a comprehensive examination of MIPS and MACRA in Medical Billing for the 2026 performance year and beyond. It will dissect the four MIPS scoring categories with their current weights and evolving measure inventories. Will explore the expanding universe of Advanced Alternative Payment Models (APMs) and the changing economics of APM participation. We will demystify Virtual Groups in MIPS and subgroup reporting requirements. We will detail MIPS data submission pathways and compliance documentation standards.

For medical billing professionals, practice administrators, and providers navigating the intersection of quality measurement and revenue integrity, this is your definitive guide to understanding, mastering, and profiting from the Quality Payment Program.

MACRA and the Quality Payment Program – A Foundational Overview

MACRA implementation created two distinct pathways for Medicare clinicians: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Understanding the distinction between these pathways and the strategic considerations governing pathway selection is essential for MIPS and MACRA in Medical Billing.

The Two Pathways

Merit-based Incentive Payment System (MIPS):
MIPS is the default payment system for the majority of Medicare clinicians. It consolidates three legacy programs—the Physician Quality Reporting System, the Value-Based Payment Modifier, and the Medicare EHR Incentive Program—into a single performance-based payment adjustment system. Clinicians are scored across four weighted categories, and their final score determines whether they receive a positive, neutral, or negative payment adjustment.

Advanced Alternative Payment Models (APMs):
Advanced APMs represent an alternative track for clinicians who participate in innovative payment models meeting specific CMS criteria. Qualifying APM participants (QPs) are exempt from MIPS reporting and receive distinct financial incentives. Historically, this included a 5% lump-sum bonus payment, but this structure is changing significantly for 2026 and beyond.

The 2026-2028 Stability Period

For the 2026 through 2028 performance years, CMS has committed to maintaining the MIPS performance threshold at 75 points. This multi-year stability commitment represents a strategic departure from previous years, during which the threshold increased annually. Practice administrators can now plan quality improvement investments with confidence that the scoring target will not shift.

However, stability does not mean stagnation. While the threshold remains constant, the measure inventories, scoring methodologies, and reporting requirements continue to evolve. MIPS Value Pathways (MVPs) are expanding, and CMS has signaled that Traditional MIPS may sunset as early as the 2029 performance period.

The Changing APM Incentive Landscape

Perhaps the most significant structural change in MACRA implementation for 2026 is the transition from APM bonus payments to differential conversion factors. Previously, Advanced APM participants received a 5% lump-sum incentive payment in addition to standard fee schedule reimbursements. This bonus expires after the 2024 performance period (impacting 2026 payments) .

Beginning in calendar year 2026, CMS is introducing two distinct conversion factors: one for clinicians participating in Advanced APMs and another for all other fee-for-service clinicians under MIPS. The 2026 APM conversion factor is $33.56 (a 3.77% increase), while the MIPS conversion factor is $33.40 (a 3.26% increase) . This differential—approximately 0.5 percentage points—replaces the previous 5% bonus.

Medical group management organizations have expressed significant concern that this reduced differential may weaken incentives for APM participation, potentially causing top-performing clinicians to reconsider APM commitment in favor of MIPS, where payment adjustments can reach up to 9% .

MIPS Scoring Categories – Weights, Measures, and Methodologies

The Merit-based Incentive Payment System evaluates clinician performance across four weighted categories. For the 2026 performance year, category weights remain unchanged from 2025:

• Quality: 30%
• Cost: 30%
• Improvement Activities (IA): 15%
• Promoting Interoperability (PI): 25%

Quality Performance Category

The Quality category maintains its 30% weight for 2026, but the measure inventory has undergone significant revision. CMS has added five new quality measures (including two electronic clinical quality measures), removed ten existing measures, and substantively updated thirty measures .

New Quality Measures for 2026:

Measure Number	Measure Name	Collection Type
#513	Patient Reported Falls and Plan of Care	MIPS CQM
#512	Prevalent Standardized Kidney Transplant Waitlist Ratio	MIPS CQM
#514	Diagnostic Delay of Venous Thromboembolism in Primary Care	eCQM
#515	Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes	eCQM
#516	Hepatitis C Virus: Sustained Virological Response	MIPS CQM

Removed Measures:
Ten measures have been removed from the inventory, including Screening for Social Drivers of Health (Quality ID 487), Connection to Community Service Provider (Quality ID 498), and Adult COVID-19 Vaccination Status (Quality ID 508) .

High Priority Measure Definition:
CMS has removed “health equity” from the definition of high priority measures, narrowing the scope to core clinical domains such as outcomes, safety, and care coordination . This change reduces the number of measures eligible for bonus points and focuses quality improvement efforts on traditional clinical quality domains.

Topped Out Measures:
CMS will continue applying alternative benchmarks for 19 topped-out measures, allowing clinicians in specialties with limited measure options to earn meaningful points despite measure saturation .

Claims-Based Measure Scoring:
A significant methodological change affects claims-based quality measures. CMS has revised the scoring methodology to align with Cost performance category benchmarking, using median-based scoring and standard deviations to determine performance thresholds. Under the previous methodology, a performance rate of 70% on the heart failure admission rate measure would have earned 5–5.9 points; under the new methodology, it earns 7–7.9 points.

Cost Performance Category

The Cost performance category remains at 30% weight with a stable inventory of 35 cost measures for 2026. No new cost measures have been added, and none have been removed.

Episode-Based Cost Measures:
CMS maintains 33 episode-based cost measures covering acute inpatient conditions, procedures, and chronic conditions. Each episode-based measure includes specific care episode and patient condition codes that define the trigger event, clinical episode, and attributed services.

Population-Based Cost Measures:
Two population-based measures continue: the Medicare Spending Per Beneficiary (MSPB) Clinician measure and the Total Per Capita Cost (TPCC) measure. CMS has updated the TPCC measure to limit instances where it is attributed to highly specialized groups based solely on billing of advanced care practitioners.

Two-Year Informational Period:
Beginning in 2026, CMS has finalized a two-year informational-only feedback period for any new cost measures finalized in future years. During this period, clinicians receive performance feedback without the measure contributing to their MIPS final score—providing practices time to understand and adapt before financial impact begins.

Improvement Activities Category

The Improvement Activities category, weighted at 15%, has received targeted updates for 2026. CMS has added three new activities, modified seven existing activities, and removed eight activities.

New Improvement Activities:

• Improving Detection of Cognitive Impairment in Primary Care
• Integrating Oral Health Care in Primary Care
• Patient Safety in Use of Artificial Intelligence (AI)

Subcategory Restructuring:
CMS has eliminated the “Achieving Health Equity” subcategory and replaced it with “Advancing Health and Wellness,” signaling a broader strategic shift toward wellness and prevention rather than social determinants of health screening .

Removed Activities:
Eight activities have been removed, including those related to clinical trial leadership, anti-racism plans, food insecurity protocols, LGBTQ care improvement, community resource engagement, and COVID-19 vaccine achievement for practice staff.

Promoting Interoperability Category

The Promoting Interoperability category maintains its 25% weight while introducing several technical updates focused on data security and reporting flexibility.

Security Risk Analysis Enhancement:
The Security Risk Analysis measure now requires an additional attestation confirming that clinicians conducted risk management activities as outlined under the HIPAA Security Rule .

SAFER Guides Update:
Clinicians must use the updated 2025 SAFER Guides for their self-assessments under the High Priority Practices measure .

TEFCA Bonus Measure:
A new optional bonus measure encourages public health data exchange using the Trusted Exchange Framework and Common Agreement (TEFCA). This is one of four available bonus measures under the Public Health and Clinical Data Exchange objective, with a maximum of 5 points available if reporting one or more bonus measures .

Measure Suppression Policy:
CMS has adopted a new measure suppression policy for the PI category, providing flexibility to suppress measures when unexpected challenges make compliance infeasible or unfair. Under this policy, CMS has suppressed the Electronic Case Reporting measure for the 2025 performance period due to CDC onboarding delays.

MIPS Value Pathways – The Future of MIPS Reporting

MIPS Value Pathways (MVPs) represent the strategic future of the Merit-based Incentive Payment System. CMS has made clear that Traditional MIPS will eventually sunset, with MVPs becoming the mandatory reporting framework. While the exact timeline remains uncertain, CMS anticipates that it may be ready to fully transition to MVPs by the 2029 performance period.

MVP Expansion for 2026

CMS has added six new MVPs for the 2026 performance year:

• Diagnostic Radiology
• Interventional Radiology
• Neuropsychology
• Pathology
• Podiatry
• Vascular Surgery

All 21 previously finalized MVPs have been updated to align with changes to quality measure inventories and improvement activities.

Subgroup Reporting Requirement

Beginning with the CY 2026 performance period (impacting 2028 payments), multispecialty groups will no longer be able to report an MVP as a single group. Instead, multispecialty groups that wish to participate in an MVP must register and report at the subgroup, individual, or APM Entity level.

Subgroup Definition:
CMS defines a subgroup as a subset of a group practice that is identified by a combination of one or more clinician Tax Identification Numbers and one or more National Provider Identifiers. Subgroups must be pre-registered with CMS and must report on a minimum of 50% of the subgroup’s NPIs.

Small Practice Exception:
Multispecialty groups with the small practice special status (15 or fewer clinicians) may continue to register to report an MVP as a group and are not required to create subgroups .

Single Specialty Determination:
Groups will self-attest their specialty composition (single-specialty or multispecialty) during MVP registration. CMS defines a single specialty group as a group consisting of clinicians in one specialty type or clinicians involved in a single focus of care .

MVP Clinical Groupings

CMS has updated the MVP table format to stratify quality measures by clinical conditions and episodes of care, creating “Clinical Groupings” that help clinicians identify relevant measures for their practice areas. When applicable, an “Advancing Health and Wellness” or “Experience of Care” clinical grouping is included for cross-cutting quality measures.

This new stratified format offers a streamlined set of quality measures to aid clinicians in selecting the most clinically relevant measures applicable to their clinical area and identifies when quality and cost measures are linked.

QCDR and Registry Implementation Timeline

Qualified Clinical Data Registries (QCDRs) and Qualified Registries will be given one year after an MVP is finalized before they are required to fully support it. This provides registries with adequate time for programming and system preparation, reducing potential withdrawal or termination due to technical implementation challenges.

Advanced Alternative Payment Models – Pathways, Incentives, and Strategic Considerations

Advanced Alternative Payment Models (APMs) offer an alternative to MIPS reporting for clinicians willing to bear significant financial risk and meet specific participation thresholds. Understanding APM qualification criteria, incentive structures, and strategic positioning is essential for comprehensive MIPS and MACRA in Medical Billing.

Advanced APM Definition

To be considered an Advanced APM, a model must be approved by CMS and meet three specific criteria:

• Requires participants to use certified EHR technology
• Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category
• Either: (a) is a Medical Home Model expanded under CMS Innovation Center authority, OR (b) requires participants to bear a significant financial risk

Significant Financial Risk:
The significant financial risk requirement has been a barrier to APM development in certain specialties. For psychiatrists and other mental health professionals who are currently underpaid, participating in Advanced APMs would require risking up to an 8% payment reduction if the model fails to produce cost savings. Meeting CEHRT requirements also presents significant challenges.

QP Status Determination

Clinicians become Qualifying APM Participants (QPs) when sufficient revenue or patients are tied to Advanced APMs. For the 2026 performance year, CMS has expanded QP determinations in two important ways :

Dual-Level Determinations:
CMS will make QP status determinations at both the individual clinician level and the APM Entity level, offering more granular eligibility tracking.

Expanded Service Inclusion:
The QP calculation has been expanded to include all Covered Professional Services, not just evaluation and management services, for better representation of participation.

Partial QP status is available for clinicians with slightly lower levels of APM participation. Partial QPs may elect not to perform MIPS reporting and will not incur a payment penalty.

The Changing Incentive Structure

APM incentive payments are undergoing fundamental transformation. The 5% lump-sum bonus, which has been available since 2019, expires after the 2024 performance period.

Participant Type	2026 Conversion Factor	Payment Update
Advanced APM Participants	$33.56	+3.77%
MIPS/FFS Clinicians	$33.40	+3.26%

Differential Conversion Factors:
Beginning in CY 2026, CMS has implemented two distinct conversion factors:

This differential—approximately 0.5 percentage points—replaces the previous 5% bonus structure. Medical group management organizations have expressed concern that this reduced differential may weaken incentives for APM participation, particularly as MIPS payment adjustments can reach up to 9% for top performers.

APM Performance Pathway

The APM Performance Pathway (APP) is the quality reporting mechanism for ACOs participating in the Medicare Shared Savings Program and other APM entities. For 2026, CMS has made several updates :

APP Plus Measure Set:
CMS has removed the Screening for Social Drivers of Health (Quality ID 487) from the APP Plus measure set.

CAHPS Survey Methodology:
Starting in performance year 2027, Shared Savings Program ACOs will be required to use a web-mail-phone approach for the CAHPS for MIPS Survey, replacing the current mail-phone method to improve response rates.

Eligible Beneficiary Definition:
CMS has revised the definition of eligible beneficiaries for ACOs reporting Medicare CQMs. Beginning in performance year 2025 and for subsequent years, a beneficiary is considered eligible if they received at least one primary care service during the performance year from an ACO professional who is a primary care physician or a specialist included in ACO assignment methodology .

MIPS Data Submission and Compliance Documentation

Successful MIPS data submission requires systematic workflow integration, continuous performance monitoring, and comprehensive documentation practices. Medical billing professionals play a critical role in ensuring their provider clients meet CMS requirements and maximize payment adjustments.

Reporting Periods

Each MIPS category has distinct reporting period requirements:

Category	Minimum Reporting Period
Quality	Full calendar year (12 months)
Promoting Interoperability	Continuous 180-day period
Improvement Activities	Continuous 90-day period
Cost	Full calendar year (claims-based, no separate reporting)

Documentation Best Practices

Real-Time Documentation:
For both Improvement Activities and Promoting Interoperability, documentation must be gathered during the performance period. Avoid waiting until year-end. For PI, save EHR screenshots, secure messaging logs, and access reports. For IA, gather training records, meeting notes, and evidence of implementation.

Security Risk Analysis Documentation:
For the PI category’s Security Risk Analysis measure, practices must maintain documentation of both the analysis and subsequent risk management activities. Attestation alone is insufficient; CMS requires evidence of ongoing security monitoring and remediation.

SAFER Guide Compliance:
Practices must document their self-assessment against the 2025 SAFER Guides. This assessment should be completed early in the performance year, with findings and corrective actions documented.

Centralized Documentation Hub:
Maintain all MIPS-related files in a secure, backed-up location. Organize documents by category and use naming conventions that include measure names and dates. If CMS audits a submission, comprehensive documentation must be readily accessible .

EHR Vendor Coordination

For practices using certified EHR technology, coordination with vendors is essential for successful MIPS data submission:

Capability Verification:
Confirm that your EHR system supports FHIR-based APIs and maintains current ONC certification.

Transition Planning:
If switching EHR systems, plan transitions in Quarter 2 or 3 to allow for training and data continuity. Coordinate with your registry and maintain a paper trail of all communications related to integration and reporting setup.

Data Preservation:
Before discontinuing access to a legacy EHR platform, run reports and capture screenshots of all MIPS-relevant data. Validate that the new system captures required fields for selected measures.

Final Submission Review

Conduct a thorough manual review of all final reports before submission. Verify that measures align with the correct performance period, all documentation is complete, and registry integrations are accurate. Submit at least two weeks ahead of the deadline to avoid last-minute errors or system congestion.

Specialty-Specific Considerations

Different specialties face distinct MIPS reporting requirements and measure availability challenges. Medical billing professionals must understand these specialty-specific nuances to optimize client performance.

Ophthalmology

The Complete Ophthalmologic Care MVP assesses outcomes in glaucoma, cataract, retinal detachment, and ocular care. Ophthalmology practices should familiarize themselves with this MVP structure and plan their transition from Traditional MIPS .

Measure Selection:
Choose measures relevant to ophthalmology practice and reflective of services provided. Avoid “topped-out” measures with low scoring potential. Review prior year performance and focus on areas where the practice can demonstrate improvement or maintain high performance.

Pathology

For the 2026 performance year, CMS has introduced the first Pathology MVP. No measures were added to or removed from the Pathology Specialty Measure Set, and Pathology QPP measures remain worth a maximum of 10 points for practices scoring 100% .

However, the Pathology MVP includes several challenges. Several Improvement Activities included in the MVP are not applicable to pathologists. The MVP also includes population health measures and Promoting Interoperability activities that do not apply to pathology practice. Practices considering MVP reporting should carefully evaluate these applicability issues.

Allergy and Immunology

CMS has not yet established an allergy-specific MVP. The Pulmonology Care MVP, established in 2025, does not offer sufficient reporting options for allergists. Professional organizations continue to advocate for appropriate reporting options under the MVP program.

The Allergy/Immunology Specialty Measure Set has been updated for 2026 with the removal of three measures (Screening for Social Drivers of Health, Connection to Community Service Provider, and Adult COVID-19 Vaccination Status). Eleven measures remain in the specialty set.

Cardiology and Cardiothoracic Surgery

Cardiothoracic surgery measures are included in the Surgical Care MVP, designed for surgical specialists to report separately from Traditional MIPS. Beginning with the 2026 performance year, mandatory subgroup reporting applies to large multispecialty groups (16+ providers) participating in this MVP.

Small and Solo Practices

CMS estimates that 49.16% of solo practitioners and 21.04% of small practices will receive negative payment adjustments for the 2026 performance year, compared to 11.92% of all MIPS-eligible clinicians.

Small Practice Protections:
Small practices (15 or fewer clinicians) retain significant flexibility in MVP reporting. Multispecialty groups with small practice special status may continue to report an MVP as a group and are not required to create subgroups.

Virtual Groups:
Virtual Groups in MIPS allow solo practitioners and small practices to aggregate performance data for MIPS reporting. This option reduces administrative burden and improves scoring stability for practices that might otherwise lack sufficient volume for reliable measure performance.

The Medical Billing Professional’s Role in MIPS Success

MIPS and MACRA in Medical Billing are not merely compliance obligations—they are revenue cycle opportunities. Medical billing professionals who understand QPP mechanics and proactively manage client performance deliver measurable financial value.

Revenue Impact Quantification

MIPS payment adjustments are applied to the entire Medicare fee schedule amount for covered professional services. A positive adjustment of 1-2% represents substantial incremental revenue for high-volume Medicare practices. Conversely, negative adjustments of 1-2% represent permanent revenue reduction that cannot be recovered through appeal or subsequent performance.

The 2026 performance threshold of 75 points creates clear financial stakes. Practices scoring 76+ points receive positive adjustments; practices scoring exactly 75 receive neutral adjustments; practices scoring below 75 receive negative adjustments.

Strategic Planning Support

Medical billing professionals should engage clients in strategic MIPS planning:

Pathway Selection:
Evaluate whether Traditional MIPS, MVPs, or APM participation offers the optimal balance of reporting burden and financial return for each client.

Measure Selection:
Analyze prior year performance data to identify measures where the client can achieve maximum points. Avoid measures with low scoring potential due to topped-out benchmarks or insufficient case volume.

Documentation System Design:
Implement EHR workflows that capture required data elements at the point of care rather than requiring retrospective abstraction.

Performance Monitoring

Establish monthly performance review processes that track:

• Quality measure performance rates against benchmarks
• Cost measure attribution events and episode costs
• Improvement Activities documentation completeness
• Promoting Interoperability attestation readiness

Early identification of performance gaps enables mid-year course correction before scoring is locked.

Audit Preparedness

Maintain comprehensive documentation for all MIPS submissions. CMS may audit any MIPS participant, and audit requests typically require rapid response with extensive supporting evidence. Practices lacking organized, accessible documentation risk adjustment reversals and payment recoupment.

Future Directions – Beyond 2026

While CMS has committed to program stability through 2028, significant changes are on the horizon for MIPS and MACRA in Medical Billing.

Traditional MIPS Sunset

CMS has signaled that Traditional MIPS will eventually be replaced entirely by MVPs. While the agency has not confirmed an exact transition date, the 2029 performance period is frequently cited as a potential sunset timeline. Practices should begin familiarizing themselves with relevant MVPs and developing subgroup reporting capabilities.

Digital Quality Measures

CMS continues its strategic shift toward digital quality measures (eCQMs) that can be captured directly from EHR data without manual abstraction. The 2026 addition of two new eCQMs continues this trajectory. Practices should ensure their EHR systems are capable of producing valid eCQM data.

APM Evolution

The transition from lump-sum APM bonuses to differential conversion factors fundamentally changes the economic calculus of APM participation. If the differential remains approximately 0.5 percentage points, top-performing clinicians may find MIPS offers superior financial returns. Congress may revisit APM incentive structures if participation declines .

Health Equity Measurement

Although CMS has removed health equity from the high priority measure definition for 2026, the agency remains committed to health equity measurement in the long term. Future rulemaking may reintroduce equity measures in reformed frameworks.

Frequently Asked Questions
MIPS and MACRA in Medical Billing

What is the MIPS performance threshold for 2026, and how does it affect my payment adjustment?

The MIPS performance threshold for the 2026 performance year (affecting 2028 payments) is 75 points. This threshold has been finalized through the 2028 performance period, providing multi-year stability. Your final score exceeds 75 points, you will receive a positive payment adjustment. If your final score equals 75 points, you will receive a neutral adjustment with no payment impact. If your final score falls below 75 points, you will receive a negative payment adjustment. CMS estimates the median final MIPS score for 2026 will be 89.47, with approximately 84% of clinicians receiving positive adjustments and 12% receiving penalties. However, solo practitioners face significantly higher penalty rates, with nearly 50% projected to receive negative adjustments.

What are MIPS Value Pathways (MVPs), and should my practice transition from Traditional MIPS?

MIPS Value Pathways (MVPs) are specialized reporting frameworks that align measures and activities around specific clinical specialties or conditions. For 2026, six new MVPs have been added, including Diagnostic Radiology, Pathology, and Vascular Surgery, bringing the total to 27 available pathways. MVPs remain optional for 2026, but CMS has signaled that Traditional MIPS will likely sunset by the 2029 performance period. Practices should begin evaluating relevant MVPs and developing subgroup reporting capabilities. Small practices (15 or fewer clinicians) retain significant flexibility and may continue reporting MVPs as groups even if multispecialty.

How have Advanced APM incentives changed for 2026, and is APM participation still financially advantageous?

The Advanced APM incentive structure has fundamentally changed for 2026. The 5% lump-sum bonus payment has expired. Beginning in calendar year 2026, CMS has implemented two distinct conversion factors: $33.56 for APM participants (a 3.77% increase) and $33.40 for MIPS/FFS clinicians (a 3.26% increase). This differential of approximately 0.5 percentage points replaces the previous bonus structure. Some medical group management organizations have expressed concern that this reduced differential may weaken APM participation incentives, particularly since MIPS payment adjustments can reach up to 9% for top performers. Practices should carefully evaluate whether APM participation remains advantageous given their specific performance capabilities and risk tolerance.

What are the most important documentation requirements for the Promoting Interoperability category?

For the 2026 performance year, the Promoting Interoperability category includes several critical documentation requirements. The Security Risk Analysis measure now requires an additional attestation confirming that clinicians conducted risk management activities as outlined under the HIPAA Security Rule—analysis alone is insufficient. Clinicians must use the updated 2025 SAFER Guides for their self-assessments under the High Priority Practices measure and maintain documentation of both the assessment and any corrective actions. A new optional TEFCA bonus measure encourages public health data exchange. All PI documentation must be gathered during a continuous 180-day period within the performance year; waiting until year-end to reconstruct documentation creates significant compliance risk.

How can small and solo practices succeed in MIPS despite limited resources?

CMS has maintained several important protections for small and solo practices. The performance threshold remains at 75 points through 2028, providing predictable targets. Small practices (15 or fewer clinicians) may continue reporting MVPs as groups even if multispecialty, avoiding the subgroup registration requirement applicable to larger groups. Virtual Groups in MIPS allow solo practitioners and very small practices to aggregate performance data, increasing measure reliability and reducing administrative burden. However, CMS estimates that 49% of solo practitioners and 21% of small practices will still receive penalties in 2026. Success requires early preparation, strategic measure selection, and often partnership with experienced medical billing professionals who can provide specialized MIPS support that individual practices cannot cost-justify independently.

MIPS and MACRA in Medical Billing-Expert Insight

Understanding MIPS and MACRA in Medical Billing requires continuous learning. The Quality Payment Program (QPP) that began in 2017 bears only partial resemblance to the mature, stable program of 2026. Performance thresholds have settled. Measure inventories have been refined. Scoring methodologies have become more sophisticated. Reporting pathways have multiplied and specialized.

Yet the fundamental architecture remains: Medicare will reward clinicians who deliver high-quality, cost-effective care and penalize those who do not. The Merit-based Incentive Payment System and Advanced Alternative Payment Models are not temporary programs. They are the permanent infrastructure of value-based Medicare reimbursement.

For 2026, CMS has provided something the healthcare community has long requested: predictability. The performance threshold is fixed at 75 points through 2028. Category weights are stable. Measure inventories, while updated, follow consistent patterns. Practices can plan multi-year quality improvement strategies without fear of annual regulatory whiplash.

But predictability is not passivity. The expansion of MIPS Value Pathways (MVPs) and the impending sunset of Traditional MIPS require proactive preparation. The transformation of APM incentive payments from lump-sum bonuses to differential conversion factors demands strategic recalculation. The tightening of Promoting Interoperability requirements around security risk management necessitates operational investment.

Medical billing professionals occupy a critical position in this environment. If translate regulatory requirements into operational workflows. It convert performance data into financial outcomes. We guide clients through pathway selections, measure selections, and submission deadlines. We are the bridge between CMS policy and provider revenue.

MIPS and MACRA in Medical Billing

MIPS and MACRA in Medical Billing are not burdens to be minimize or risks to be mitigate. They are opportunities to demonstrate value, differentiate services, and deliver measurable financial returns. Practices that master MIPS reporting do not merely avoid penalties—they earn payment adjustments that compound year after year. Practices that achieve QP status in Advanced APMs position themselves at the leading edge of healthcare transformation.

EZMedPro exists to ensure our clients are among these successful practices. Medical billing professionals maintain current certification in MIPS reporting pathways. Our technology platforms automate quality measure tracking and submission validation. Our consulting services guide practices through MVP transitions and APM evaluations. We do not merely process claims; we optimize value-based revenue.

The 2026 performance year is underway. CMS has set the rules, established the measures, and defined the scoring. Success belongs to practices that prepare early, document thoroughly, and monitor continuously. Success belongs to practices that partner with medical billing professionals who understand MIPS and MACRA in Medical Billing not as compliance obligations but as strategic opportunities.

EZMedPro. Value-Based Billing Expertise.

Trusted Industry Leader

Is your medical billing practice prepared for the 2026 MIPS performance year?

The 75-point threshold is fix. The measure inventories are finalize. The reporting pathways are define. Success requires systematic preparation, continuous monitoring, and expert guidance.

Contact EZMedPro today for a comprehensive MIPS Readiness Assessment.

Our value-based reimbursement specialists will analyze your current MIPS performance, identify scoring opportunities, and develop a customized reporting strategy aligned with your practice’s clinical focus and operational capabilities.

Master MIPS. Optimize APM. Maximize Revenue.