The MIPS Question Nobody Asks Until It’s Too Late: “Wait, Was I Supposed to Report?”

By Tatyana Kantor CFPC, CPB, Billing Department, WCH

How TIN/NPI eligibility, low-volume thresholds, and CMS’s final determination can change what a practice needs to do — and when.

Every year, somewhere between the last EHR upgrade and the first flu-shot rush, a practice manager logs into the QPP portal — or, more often, notices something off while reconciling a batch of Medicare remits well into the payment year — and feels a small drop in their stomach. A payment adjustment shows up that wasn’t there before, and it isn’t positive. And the question that follows is always the same one, asked a year too late: were we even supposed to report MIPS this year?

That question has a knowable answer, months before the reporting window opens. This piece is about getting to that answer early, understanding what actually drives it, and building a habit around it — because some of the most avoidable MIPS problems arise not from a poor performance score, but from failing to determine eligibility in the first place.

Eligibility Isn’t a Guess. CMS Calculates it from Your Data.

A lot of confusion around MIPS comes from treating eligibility like a judgment call — “we’re a small practice, this probably doesn’t apply to us” — when it’s actually a mechanical determination CMS runs on your data, at the TIN/NPI level, at defined points in the cycle.

Here’s the logic, stripped of the acronym soup:

You’re a MIPS eligible clinician if you fall into one of the recognized clinician types (physicians, PAs, NPs, clinical nurse specialists, CRNAs, physical and occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and dietitian/nutrition professionals, among others), and you clear the low-volume threshold, and you’re not otherwise exempted by newly enrolling in Medicare or by achieving Qualifying APM Participant (QP) status through an Advanced APM.

The low-volume threshold is where most of the real-world surprises happen. To be required to report, you must exceed all three of these in both 12-month segments of the MIPS determination period: billing more than $90,000 in Medicare Part B allowed charges for covered professional services, providing care to more than 200 Medicare Part B beneficiaries, and furnishing more than 200 covered professional services to Medicare Part B patients. If you don’t exceed all three elements in both segments, you may not be required to participate — but that does not necessarily mean you’re fully exempt. Depending on how many threshold elements you exceed, you may be opt-in eligible. Fall short on even one of the three, in either segment, and your status changes — either to fully exempt, or to something in between, which is a distinction worth its own section below.

And here’s the point that trips up multi-site providers: MIPS eligibility is determined at the individual clinician level for each TIN/NPI association — not for the clinician as a whole person across every place they bill. A clinician’s status can differ across different TIN/NPI associations, so “Dr. Alvarez isn’t required to report” may not actually answer the question, if Dr. Alvarez bills under more than one Tax Identification Number. It’s a TIN/NPI-by-TIN/NPI question, not simply a doctor-by-doctor one.

The Dangerous Part: Preliminary Eligibility Isn’t Necessarily Final

CMS doesn’t make this determination once and leave it alone. Eligibility is assessed across two separate 12-month segments of the determination period, and CMS runs the low-volume threshold check against both. That structural detail is exactly why “we checked once, we’re fine” is a dangerous sentence in a MIPS conversation — a clinician’s status after the first segment and their status after the second can genuinely differ, because they reflect two different measurement windows, not just a formality repeated for CMS’s own bookkeeping.

Timing matters here, and it’s worth being precise: CMS issues a preliminary determination before the performance year even begins, and a final determination in December of the performance year itself. For the 2026 performance year specifically, that means a preliminary read was issued ahead of January 1, 2026. The preliminary determination is an early planning signal, not necessarily the last word — treat it as a heads-up, not a verdict. The final determination follows in December 2026, and practices should use that final determination as a final eligibility checkpoint while building their reporting plan well before the submission window opens.

It’s also worth naming what actually moves a practice across the threshold between those two checkpoints, because it’s rarely dramatic. A practice that adds a new service line, extends hours, opens a satellite location, or simply grows its Medicare panel through normal patient acquisition can cross the low-volume threshold without anyone in the practice deciding to change anything MIPS-related at all. Growth in what the practice performs — not just growth in headcount — is often the quiet driver behind a status that flips between preliminary and final.

The Group-Reporting Trap

There’s a scenario CMS’s own eligibility guidance spells out clearly: a clinician can sit below the individual low-volume threshold while the practice — the TIN as a whole — sits above it. If the practice chooses to participate and reports at the group level, that clinician’s performance is included in the group submission, and the clinician can receive the group’s MIPS payment adjustment, even though they wouldn’t have been required to report on their own.

Group participation itself is optional, not automatic — for practices participating in Traditional MIPS, group reporting is generally an election rather than an automatic requirement. But the choice has real consequences for individually-exempt clinicians riding along inside it, which makes the group-versus-individual reporting decision a strategic one, not merely an administrative box to check. That means a practice cannot determine its reporting strategy simply by looking at each clinician’s individual status in isolation — individual eligibility, group eligibility, and the separate decision of how to report (individually or as a group) are three different questions, and a practice with a mix of high-volume and low-volume Medicare clinicians should be answering all three deliberately.

Once eligibility is established, the next question is obvious: what is actually at stake if the practice gets MIPS wrong?

What the 9 Percent Actually Means — and Where the Confusion Usually Creeps In

For the 2026 performance year, CMS held the structural pieces steady: the performance threshold to avoid a penalty stays at 75 points, held there through the 2028 performance year, category weights are unchanged, and the low-volume threshold itself is unchanged. That relative policy stability matters because practices can plan around known thresholds rather than a moving target.

Here’s where it’s easy to get the numbers tangled, though. The maximum negative adjustment under MIPS is 9 percent, applied to Medicare Part B payments in the corresponding payment year — for the 2026 performance year, that’s the payment year beginning January 1, 2028. The positive side works differently: it’s budget-neutral and depends on a scaling factor CMS calculates only after performance results across the whole eligible population are known. There’s no way to know in advance what that scaling factor will land on for a given performance year — which is itself the point. The downside is fixed and known well ahead of time; the upside is variable and only knowable in arrears.

For many eligible practices, that asymmetry means MIPS now functions less like a bonus opportunity and more like a downside-management exercise. The practical financial question is often not “how do we maximize the bonus,” but “how do we avoid an unnecessary negative adjustment.”

That reframing also matters for how “failing to report” should be understood. Failing to submit data doesn’t mean CMS simply applies a flat 9 percent penalty in every case — the final adjustment is tied to the final score CMS is able to calculate, and an eligible clinician who does not submit required data and does not otherwise qualify for an exception can end up with a final score low enough to receive the maximum negative adjustment. The scale between the maximum adjustment and a neutral outcome is a gradient, not a switch. That is precisely the scenario worth building a calendar around avoiding.

The Operational Problem Nobody Calls MIPS

Here’s the analytical point that’s easy to skip past. Many practices that receive an unexpected negative payment adjustment don’t get there because they misunderstood the policy. They get there because their internal data didn’t match what they assumed. A new hire whose Medicare enrollment date changed the group’s exemption status mid-year without anyone flagging it. A billing-rights reassignment that landed in the practice’s own records a quarter later than it took effect with CMS. A new service line or added location that quietly pushed Medicare patient volume past the threshold before anyone thought to check.

MIPS eligibility, in other words, is downstream of your billing hygiene, not upstream of it. If your TIN/NPI mapping is messy, your understanding of your MIPS status can be wrong before you ever open a quality measure spec. The fix isn’t a MIPS-specific tool — it’s the boring, unglamorous discipline of reconciling your own data against CMS’s on a regular cadence. A practical quarterly check should run through:

• TIN/NPI associations for every rendering provider
• Medicare enrollment status and enrollment dates for new hires
• Part B allowed charges billed to date
• Medicare Part B patient count
• Number of covered professional services furnished
• Group-level totals against the low-volume threshold, not just individual totals
• New, terminated, or reassigned providers whose billing rights changed mid-year
• The current result from the QPP Participation Status Tool for every active NPI

None of that is glamorous work, but it’s the actual mechanism by which a practice avoids finding out its MIPS status the hard way.

Exempt, Opt-in Eligible, or Voluntary — These Are Not the Same Thing

This is where the terminology genuinely matters, and where a lot of otherwise careful explanations go soft. Falling short of the full low-volume threshold doesn’t put every clinician into the same bucket. CMS actually distinguishes between two different situations:

• Not exceeding any of the three low-volume threshold elements — you’re exempt, with no MIPS reporting obligation at all. You can still choose to voluntarily report under Traditional MIPS, which gets you performance feedback but carries no payment adjustment either way, positive or negative.
• “Opt-in eligible” — you exceed one or two of the three low-volume threshold elements, but not all three. This is a distinct status, and it comes with a real choice: you can opt in and become subject to the full MIPS payment adjustment (upside and downside both), or you can decline and simply report voluntarily instead, with no payment consequence. One important detail — once an election to opt in is made for a given performance year, it’s irreversible for that year.

The mistake is treating “not fully eligible” as a single, uniform category. It isn’t. A clinician who clears zero of the three threshold elements is in a fundamentally different position than one who clears two of three, and the second group has a genuine strategic decision to make that the first group doesn’t. For a practice growing its Medicare panel and expecting to cross the full threshold on its own next cycle anyway, opting in a year early can build reporting muscle memory before the financial stakes are unavoidable. For a practice with shrinking Medicare exposure, staying exempt or reporting voluntarily under Traditional MIPS is usually the more sensible call.

Knowing whether a clinician is required, opt-in eligible, or exempt is only the first decision, though. The next question is operational: what does the practice actually have to collect, document, and submit to produce a score that holds up?

What Eligibility Means Once You’re Required to Participate

Once a clinician is determined to be required to participate — or chooses to opt in — the question changes. It’s no longer simply “do I have to report?” It becomes: “what does a defensible MIPS submission actually require?” That’s a different kind of question, and it’s where a lot of otherwise well-prepared practices lose points they didn’t need to lose.

What gets reported. Under Traditional MIPS, scores are based on four performance categories: Quality, Improvement Activities, Cost, and Promoting Interoperability. For 2026, the default category weights are Quality 30 percent, Cost 30 percent, Promoting Interoperability 25 percent, and Improvement Activities 15 percent — unchanged from 2025. Cost is the one category clinicians never submit data for directly; CMS calculates it entirely from claims already on file. The other three depend on data being reported or attested through whatever submission mechanism the practice is using.

Which categories apply to which clinician. Not every clinician reports all four categories the same way. Small practices (15 or fewer clinicians) are automatically reweighted for Promoting Interoperability; if the category isn’t reported, its weight is reweighted into other performance categories rather than simply disappearing. Clinicians with qualifying special statuses — non-patient-facing, hospital-based, ASC-based, or rural, among others — can have one or more categories reweighted or excused entirely. And clinicians reporting through a MIPS Value Pathway (MVP) work from a narrower, specialty-aligned measure set rather than the full general inventory. None of this is a one-size-fits-all determination, which is exactly why it needs to be checked per clinician rather than assumed at the practice level.

What data has to exist before submission. Quality measures are subject to CMS data-completeness requirements, which for 2026 generally require data completeness of at least 75 percent, subject to measure- and collection-type-specific rules. That means partial-year or partial-population data isn’t enough on its own; the measure has to be populated at the required rate to count. Promoting Interoperability requires a continuous 180-day reporting period using certified EHR technology. Improvement Activities require attesting to specific activities performed for a minimum continuous 90-day performance period. Each category has its own timing and completeness rules, and missing the rule — not just missing the deadline — is what quietly deflates a score that looked fine on paper.

Where the data actually comes from. In practice, it’s rarely one clean source. Quality data can come from the EHR directly, from claims, or through a qualified registry or QCDR that aggregates and formats it for submission. Promoting Interoperability data comes from the certified EHR itself. Improvement Activities are attestation-based — the practice affirms the activity was performed, and needs to be able to back that up. Cost is CMS’s own claims data, with no practice-side submission at all. A practice that assumes “our EHR handles MIPS” often discovers, too late, that only one of the four categories was ever actually flowing through that system.

Documentation. A submitted score isn’t necessarily the end of the practice’s recordkeeping obligation. CMS may request supporting documentation during a targeted review, and the burden is on the practice to produce it. That generally means retaining the underlying patient-level records supporting each quality measure’s numerator and denominator, evidence that an improvement activity was actually performed (not just attested to), and PI-related system logs, for a period practices should confirm against current CMS retention guidance rather than assume matches a general medical-records retention policy.

Where this typically breaks down operationally. A few patterns show up again and again: data captured inconsistently across providers or locations, so the same measure gets coded differently depending on who’s seeing the patient; numerator/denominator mismatches that inflate or deflate a measure’s real performance; confusion between what was captured at the individual clinician level versus what should have been aggregated at the group level; improvement activities attested to without anything on file to demonstrate they happened; and, most simply, a final submission that doesn’t actually match the source records it was supposedly built from. These are ultimately data-integrity problems that happen to surface through MIPS reporting — the same theme running through this entire piece, just one layer deeper.

The 2026 Calendar that Actually Matters

Mark this now: the regular submission window for the 2026 performance year runs from January 4, 2027 to March 31, 2027, at 8 p.m. ET. Data can go in through the QPP portal directly, through your certified EHR, or through a qualified registry or QCDR — but whichever pipe you use, that pipe needs to be tested and working well before the window opens, not in the final week of March. Practices should plan around that closing date as firm, rather than assuming a late-submission grace period will be available.

Practically, that means:

• Once CMS publishes the final eligibility determination in December 2026: reconcile it against your practice’s own TIN/NPI roster — not just the clinicians you think bill Medicare heavily.
• Q4 2026: run a mock data pull through whichever submission mechanism you’re using. Testing your data feed early reduces the risk of discovering a formatting or connectivity problem right as the window is closing.
• Before March 31, 2027, 8 p.m. ET: submit.

Practices affected by a federally declared disaster should also check CMS’s 2026 Extreme and Uncontrollable Circumstances (EUC) guidance before assuming they have no relief option.

The One-Sentence Version

Check your TIN/NPI eligibility early, recheck it once CMS issues its final determination in December, decide deliberately whether to participate, and then make sure the data behind your submission is complete, documented, and ready before the reporting window closes. In MIPS, knowing that you have to report is only half the job — you also need to be able to prove what you reported.

Sources

• CY 2026 Medicare Physician Fee Schedule Final Rule, 90 FR 49266 (November 5, 2025)
• 2026 Quality Payment Program Final Rule Fact Sheet and Policy Comparison Table, qpp-cm-prod-content.s3.amazonaws.com
• QPP MIPS Participation Fact Sheet, cms.gov/files/document/qppmipsparticipationfactsheetpdf
• QPP Participation Status Tool, qpp.cms.gov
• 2026 Quality Payment Program Key Dates and Deadlines, qpp.cms.gov
• 2026 MIPS Annual Call for Cost Measures Fact Sheet, mmshub.cms.gov
• 2026 Quality Quick Start Guide, QPP Resource Library
• 2026 Promoting Interoperability Quick Start Guide, QPP Resource Library
• MIPS: 2025 Opt-in and Voluntary Reporting Election Guide (December 2025), via Rural Health Information Hub
• MIPS Extreme and Uncontrollable Circumstances (EUC) Exception guidance, qpp.cms.gov

Supporting reading

• MDinteractive, “Breaking Down the 2026 QPP Final Rule: Key MIPS & ACO Updates,” “2026 MIPS Rules,” and “Your Final 2025 MIPS Eligibility Is In — Here’s What to Do Next” (mdinteractive.com)
• VBCA, “2026 MIPS Reporting Guide: Requirements & Deadlines” (vbca.com)
• Medisysinc, “QPP Update: Key MIPS Registration Deadlines, Performance Data, and Compliance Announcements for 2026”