Can I hit a MIPS 75-point threshold without a full-time data analyst?

Yes. The 75-point threshold requires strategic measure selection, not a data team. Most small practices fail MIPS not because their clinical quality is poor, but because they report on measures where their patient population creates unfavorable denominators.

MIPS is not primarily a data analysis problem—it is a strategy and workflow problem. The practices that consistently score above 75 without dedicated analytics staff share three characteristics: they select measures deliberately based on their patient panel, they treat PI attestation as an operational workflow rather than an annual event, and they document Improvement Activities against the CMS catalog rather than assuming their activities qualify automatically.

The Improvement Activities category is the single easiest 15 points available in MIPS. It requires completing two medium-weight activities or one high-weight activity from CMS's catalog of 104 approved options. Many qualifying activities are things practices are already doing: care coordination for high-risk patients, same-day access for urgent visits, patient safety checklists. The only requirement is that these are documented against specific activity IDs. A practice manager can complete this work in 4–6 hours annually without any data analysis capability.

Promoting Interoperability is worth up to 25 points and is highly achievable for any practice using a certified EHR. The required measures—e-prescribing, CPOE, patient access, and health information exchange—are typically functions that practices already perform. The failure mode is documentation: not collecting the numerator/denominator data needed to attest to each measure during the performance year. A simple tracking spreadsheet updated quarterly eliminates this problem entirely.

The denominator trap is the most common hidden failure mechanism in MIPS. A practice that reports on diabetes control measures (HbA1c <8%) with a high-poverty patient panel may have genuine performance challenges driven by social determinants of health—food insecurity, medication cost barriers, transportation to pharmacy. The measure performance rate will look poor, but the clinical quality is not poor relative to the patient population served.

By selecting different Quality measures where their patient panel naturally performs well—preventive care rates, depression screening, blood pressure documentation—the same practice can score in the top quartile. The clinical care hasn't changed. Only the measure selection has. Standard MIPS dashboards don't show you this optimization opportunity. They show you current performance, not the hypothetical performance you would achieve on alternative measures.

CMS's small practice bonus of 6 additional points for practices with 15 or fewer eligible clinicians is applied automatically, but many small practices don't account for it in their score projections. A practice projecting 69 points and assuming they'll miss the threshold may actually land at 75 once the small practice bonus is applied.

Conduct a measure selection audit at the start of each performance year—before January 1 if possible, but no later than March. Pull your patient panel composition: chronic condition prevalence, demographic breakdown, insurance mix. Then evaluate the top 20 Quality measures for your specialty and estimate your likely performance on each based on existing clinical workflow documentation. Select the six measures where your panel gives you the strongest natural performance advantage.

Assign one staff member as MIPS coordinator—not a data analyst, but someone in a care coordination or practice management role. Their quarterly MIPS tasks should take 2–3 hours per quarter: verify PI measure data is being collected, confirm IA documentation is complete, and review the quality measure dashboard for any measures approaching performance concerns.

Consider MVP reporting options for 2026 if eligible for your specialty. MVP (Merit-based Incentive Payment System Value Pathways) allows reporting through a curated set of measures aligned to specific care areas, reducing the burden of measure selection while typically improving scores for practices in qualifying specialties. CMS has expanded MVP availability significantly for the 2026 performance year.