Every January a practice manager tells us MIPS is "handled" because the EHR vendor has a dashboard. Every March, fifteen months later, the same manager discovers the dashboard was tracking measures the practice never met, the Promoting Interoperability window was never started, and the final score is 52. The 2024 performance year is half over as of this week. This is the month to find that out while it can still be fixed, because several of the things that decide the score have to be started, not just submitted, before the year ends.
A short refresher on what is at stake. For the 2024 performance year, the performance threshold is 75 points. Score below it and the 2026 Medicare Part B payment adjustment is negative, on a sliding scale down to minus 9% for the lowest scores. Score above it and the adjustment is positive, but small, because the program is budget neutral and most clinicians clear the bar. The money is real, but it is not where most practices think it is, and we will show the math below.
Key takeaways
- The penalty is a sliding scale: a score of 74 costs a fraction of a percent, a score of 50 costs about 4%, and no submission at all costs the full 9% of 2026 Part B payments.
- The Promoting Interoperability window is 180 continuous days in 2024, so it must begin by July 5 or it cannot be completed this year.
- Small practices (15 or fewer clinicians) have Promoting Interoperability reweighted automatically if they do not submit it, which is a fallback, not a plan.
- Quality measures need data on at least 75% of eligible patients across all payers and at least 20 cases each; check both numbers now, while a measure can still be swapped.
- The Extreme and Uncontrollable Circumstances application, which CMS opened in June and which covers the Change Healthcare disruption, is due December 31.
What the score is actually worth
The adjustment for a score below 75 is linear between two points. A score at or below one quarter of the threshold, which is 18.75 points, receives the full minus 9%. A score of 75 receives zero. Everything between is a straight line. Take a fictional practice with $1.2 million in Medicare Part B allowed charges.
| 2024 final score | 2026 adjustment | Effect on $1.2 million in Part B |
|---|---|---|
| No submission (score 0) | Minus 9.0% | About $108,000 less |
| 30 | Minus 7.2% | About $86,000 less |
| 50 | Minus 4.0% | About $48,000 less |
| 60 | Minus 2.4% | About $29,000 less |
| 74 | Minus 0.2% | About $2,000 less |
| 75 to 100 | Zero to a small positive amount | Depends on the national pool |
Two conclusions. First, the cliff is not at 74 versus 76; it is between doing nothing and doing something. A practice that submits even a partial year in Improvement Activities and Quality moves off the bottom of the scale. Second, the scores that hurt, in the 40s and 50s, almost always come from a missing category rather than weak performance everywhere. That is why the mid-year review is organized by category.
Who is eligible and how you report
Run every NPI through the QPP participation status lookup using the practice's TIN. Eligibility is determined per clinician and per TIN, and it changes when a clinician joins or leaves, or when the practice crosses the low-volume threshold (more than $90,000 in Part B allowed charges, more than 200 Part B patients and more than 200 covered services, all three). The lookup also tells you whether the practice qualifies as a small practice (15 or fewer clinicians), which matters for bonus points, for the Improvement Activities requirement and for Promoting Interoperability reweighting. Decide, in writing, whether you are reporting as a group or as individuals. Groups report once and every eligible clinician under the TIN receives the group score; individuals report for each NPI. A clinician who joined mid-year may also be scored under a previous practice's TIN, which is their problem to track but your problem when they ask.
The category weights, and the mid-year question for each
| Category | 2024 weight | Minimum performance period | Mid-year question |
|---|---|---|---|
| Quality | 30% | Full calendar year | Are six measures collecting data, with at least one outcome or high-priority measure? |
| Cost | 30% | Full calendar year, calculated by CMS from claims | Nothing to submit; know which cost measures you are likely to be attributed |
| Promoting Interoperability | 25% | Minimum 180 continuous days in 2024 | Has the 180-day window started? If not, it must start by July 5 |
| Improvement Activities | 15% | 90 continuous days | Have the activities been chosen and is the documentation being kept? |
The Promoting Interoperability line is the one that catches practices. The minimum performance period for PI in 2024 is 180 continuous days, up from 90 in earlier years. Counting back from December 31, the latest possible start is July 5. A practice that has not begun tracking its PI measures by then cannot complete a compliant window this year. The security risk analysis and the SAFER Guides attestation both have to be completed within the calendar year as well, and the risk analysis is the one that zeroes the whole category when it is missing.
The quality data you can still influence
Ask your EHR or registry for a current-year performance report on the six measures you chose. Look at three things. The denominator count: a measure with 12 eligible patients will not score well, and a measure with fewer than 20 cases is not scored on performance at all. Data completeness: for 2024, each measure must be reported on at least 75% of the eligible patients across all payers, not only Medicare, and practices that run measures on Medicare patients only fail this quietly. And the performance rate against the benchmark deciles: a measure that is topped out, or that has no benchmark, caps at a low number of points no matter how well you do.
If two of your six measures look weak, there is time to swap them, but only if data collection for the replacement covers the full year, which for most measures means the data already exists in the chart and just needs to be mapped. A common example in primary care: swapping a screening measure with a 14-case denominator for controlling high blood pressure, where the practice has 600 hypertensive patients and readings in every visit note. The data is there. The measure was simply never turned on.
Small practices, MVPs and exceptions
Three things that depend on your situation. Small practices have Promoting Interoperability reweighted automatically if they do not submit PI data; the 25% moves to the other categories, mostly Quality. If a small practice does submit PI data, it is scored on it. In our experience a small practice with certified EHR technology that can complete a 180-day window usually scores higher by reporting, because a high PI score is easier to earn than the equivalent points in Quality. Do the math both ways before deciding to skip it.
MIPS Value Pathways are optional in 2024. For some specialties, an MVP is a cleaner set of measures with fewer choices. For others, traditional MIPS still scores better. Do not switch in July without modeling both. Registration for MVP reporting runs until December 2, so the decision does not have to be made this month, but the analysis should be.
The Extreme and Uncontrollable Circumstances exception application for 2024 opened in June and is due December 31. CMS has said it covers clinicians affected by the Change Healthcare disruption, and it can reweight any or all four categories. If your practice lost months of data or reporting capability in the spring, read the criteria now rather than in December, and keep the evidence of the disruption, such as clearinghouse notices and the dates claims stopped and resumed.
Mistakes that cost points
Choosing measures in January based on what the EHR offers rather than what the practice actually does well. Assuming the vendor submits automatically; most require you to review and approve the submission in the window that opens in early January 2025 and closes at the end of March. Missing the PI security risk analysis attestation, which zeroes the entire category. Forgetting that a clinician who joined mid-year may be scored under a previous practice's TIN as well. Reporting Improvement Activities without keeping the documentation that proves them, which is what an audit asks for. And treating the Cost category as untouchable; you cannot submit it, but you can understand which episodes you are attributed and manage utilization in the second half.
Questions we hear
We are a small practice. Can we skip Promoting Interoperability?
You can, and if you submit nothing for PI the category is reweighted automatically. Whether you should is a scoring question. With PI reweighted, Quality carries most of the weight, and a practice with weak Quality measures may end up below 75 anyway. If you have certified EHR technology and can complete a 180-day window, reporting is usually the better score.
Is 75 points realistic for a practice that has never scored above 60?
Usually yes, if Improvement Activities are fully credited (a small practice needs fewer activities), PI is completed rather than skipped, and the six quality measures are chosen for performance rather than convenience. The scores we see below 60 are almost always missing a whole category, not underperforming across the board.
Who should own this in the practice?
One named person with a monthly check, and a provider champion who will talk to colleagues about documentation. Our PCMH annual review and closing gaps in care work overlaps heavily with the quality measures most primary care practices report, and our training courses include a session on reading a MIPS performance report.
What to do this month
- Run every NPI through the QPP participation lookup and write down who is eligible, whether you are a small practice, and whether you report as a group or individuals.
- Confirm the Promoting Interoperability window has started, or start it before July 5, and schedule the security risk analysis and SAFER Guides attestation.
- Pull the current-year quality report and check each measure for 20 cases, 75% data completeness across all payers, and a usable benchmark.
- Swap any measure that fails those tests for one whose data already exists in the chart.
- Choose the Improvement Activities, start the 90-day window if it has not begun, and open a folder for the documentation.
- If the Change Healthcare outage disrupted your data, read the Extreme and Uncontrollable Circumstances criteria and gather the evidence now.
