Your MIPS Score Arrived. Did Your Reporting Weaknesses Come With It?
You opened your MIPS performance feedback and checked the score. Maybe you were relieved. Maybe you had questions. Maybe you forwarded it to leadership and returned to the dozen other things waiting for you.
Before you close that file, ask one more question: Could your practice explain how it earned that result and repeat the process without relying on the same person to rescue it?
CMS has made 2025 MIPS final scores available. This makes it a good time to examine both your performance and the work behind it. An acceptable result can still leave important questions unanswered about missing data, manual corrections, vendor oversight, and responsibility. Your October review should bring those questions into the room.
1. What Should You Review After Receiving Your MIPS Score?
Review your category results, the data behind them, unresolved discrepancies, and the work required to complete reporting. Then decide whether you need to investigate a possible scoring error, improve your current reporting process, or do both.
I recommend opening two files: your CMS feedback and your internal reporting record. The first shows the result. The second should help explain the decisions, corrections, and approvals that produced your submission.
Start with questions your team can answer:
Which results differed from our expectations?
Which measures required repeated corrections?
What remained unresolved when we submitted?
Which decisions lack a written explanation?
These questions turn a MIPS score review into a management discussion. They also give practice managers and physicians a clearer picture of where staff time went.
A score cannot tell you that your coordinator spent three evenings repairing a file. Your coordinator certainly can. Ask before that experience becomes next year’s reporting plan.
2. Separate a Possible Scoring Error From a Reporting Weakness
A disappointing score does not automatically mean CMS made an error. A reassuring score does not establish that every part of your process worked well.
A targeted review is the process through which QPP participants can ask CMS to review participation status, a MIPS final score, and the related payment adjustment. Examples of potentially valid issues include data submitted under the wrong TIN or NPI, or an approved reweighting that is not reflected in the score. CMS also identifies reasons that do not qualify, such as disagreement with a historical benchmark.
If you suspect an error, preserve the relevant records and promptly check the current CMS instructions. CMS describes the targeted review window as approximately 60 days; confirm the specific closing date rather than calculating your own deadline. (qpp.cms.gov)
At the same time, investigate internal weaknesses. An undocumented correction or unclear vendor responsibility may need attention even without a basis for a targeted review.
Give each issue a clear next action. “Investigate the score” and “repair the reporting workflow” require different work.
3. Find the Workarounds That Kept Reporting Moving
Ask your team: What did we have to do manually to finish?
That question often produces a more useful answer than asking whether reporting went well.
Your practice may have relied on spreadsheet edits, repeated exports, missing-record searches, or one employee’s knowledge of a vendor’s file requirements. A workaround can solve an immediate problem. Repeating it without examining the cause can create a fragile process.
For each workaround, document what happened, why it was necessary, and whether the underlying problem remains.
For example, if someone manually added records from a second location, ask why the routine feed did not include them. If a registry required several replacement files, determine whether the problem involved extraction, formatting, measure logic, or something else.
Do not assume every manual task needs automation. First decide whether the task reflects a legitimate review step or a recurring failure.
The goal is a sustainable MIPS reporting strategy that your team can explain and maintain without an annual rescue operation.
4. Examine the Decisions Only One Person Can Explain
A practice can have organized folders and still depend heavily on one person’s memory.
Ask who can explain why the team selected a measure, changed a data mapping, accepted an exclusion, or approved a final file. Then ask where that explanation lives.
If the answer is “Ask our coordinator,” you have found something worth documenting.
Create a short decision record that identifies:
The question or discrepancy.
The applicable performance-year specification or guidance.
The evidence reviewed.
The decision, reviewer, and date.
Keep the explanation specific enough that another qualified team member could follow it. “Vendor confirmed” needs more detail: confirmed what, using which records, and with what conclusion?
This supports MIPS documentation and staff continuity. It also helps prevent an old decision from becoming an unwritten rule that carries into a new performance year.
Good staff should bring judgment to reporting. They should not have to serve as the practice’s only searchable archive.
5. Verify the Data Behind a Reassuring Measure Result
Measure verification belongs in the review, but it should begin with a specific question.
Can we trace this reported result back to the population and records it should include?
The denominator is the population eligible for a measure under its specifications. The numerator is the portion that meets the measure’s criteria. Depending on the measure, the counting unit may involve patients, encounters, or another defined unit.
That matters when you compare an EHR report with a registry result. Two counts may differ for a valid reason. An encounter total is not automatically a measure denominator.
Choose one measure with an unexpected result or a history of corrections. Confirm its performance year, collection type, population rules, exclusions, and reporting scope. Then trace selected records through the reporting process.
Investigate unexplained differences before accepting the dashboard.
Missing records do not automatically indicate a lower score or penalty. They indicate that your team needs to determine whether the reported population and calculation are accurate.
That is the purpose of MIPS quality measure validation: establishing what the result represents.
6. Clarify What Your Registry, EHR Vendor, and RCM Partner Own
“Our vendor handles MIPS” is too broad to guide a reporting review.
A registry may calculate measures and submit data. An EHR vendor may support extraction. An RCM partner may manage billing and identify issues that need escalation. The actual responsibilities depend on your agreements and working arrangements.
Compare those arrangements with the tasks your practice expects someone to perform.
Who checks that all relevant locations and clinicians appear in the data? Who investigates failed transfers? Who approves corrections? Who retains submission confirmations? Who reviews the CMS feedback?
Name both the person performing each task and the person accountable for its completion.
For RCM partners, this is an opportunity to strengthen the client relationship through clear recognition and referral. When reporting work falls outside your scope, help the practice identify the appropriate specialist and document the handoff.
Vendor oversight should produce a usable answer when something goes wrong. A meeting invitation alone does not count as an escalation plan.
7. Give Each Performance Category Its Own Review
Do not let a strong Quality result end the discussion.
Your reporting review should address each applicable category and account for your reporting pathway, eligibility, special statuses, and any reweighting.
For Promoting Interoperability, ask whether the team can locate the records supporting its reported measures and attestations. For Improvement Activities, examine what the practice actually performed and how it documented participation and timing.
CMS’s 2026 traditional MIPS guidance states that improvement activities generally require a continuous 90-day period, unless the activity specifies otherwise. It identifies October 3 as the start of the last continuous 90-day period in 2026. Do not assume you can begin a new full-period activity later in October and complete it by year-end.
For Cost, investigate the feedback available to your team rather than treating it as a number nobody can discuss.
Keep prior-year findings separate from current-year requirements. A lesson from 2025 can guide your review without replacing the specifications that apply to 2026.
8. Turn the Debrief Into an Owned Action Plan
Now bring the findings together in a short working document: “What Our MIPS Score Did Not Tell Us.”
Use one row per issue. Record the evidence, responsible person, next action, and completion date. Add how the team will confirm that the correction worked.
An illustrative entry might read: “The second location required a manual export. The reporting lead will investigate feed coverage with the vendor, document the resolution, and reconcile the next scheduled extract.”
That is more useful than “Improve data quality.”
Start with problems that could affect reporting completeness, accuracy, or timely completion. Address recurring burdens next. Avoid assigning ten urgent projects to the same person who already rescued the last submission.
At the next meeting, ask what changed and what remains unexplained. Your pre-submission MIPS review should show progress in the underlying process, not simply a growing collection of checklists.
Use Your MIPS Feedback to Strengthen the Next Submission
Your MIPS score deserves attention. So does the work your team performed to produce it.
Use this month to identify recurring repairs, document decisions, reconcile unexplained data differences, and clarify vendor responsibilities. A strong review should leave your practice with fewer unanswered questions and a plan someone actually owns.
You do not need to investigate every measure at once. Begin with the result that surprised you, the correction that kept recurring, or the task only one person could explain.
Ask Chirpy Bird for a MIPS Second Opinion. Share your recent QPP feedback, measure list, and reporting pathway so we can help you examine your strategy and prioritize the questions that need attention. You do not need to include patient information to begin.
Request your MIPS Second Opinion
