Why did our hospital lose money in MIPS incentives last quarter?

With the 2026 performance threshold at 75 points, practices scoring below this face a negative payment adjustment of up to 9%. The most common failure points are incomplete quality measure reporting (missed denominators), insufficient Promoting Interoperability attestation, and zero credit on improvement activities.

MIPS scoring in 2026 has four weighted categories: Quality (30%), Cost (30%), Promoting Interoperability (25%), and Improvement Activities (15%). A score of 71.2 points—just below the 75-point threshold—almost always reflects weakness in one or two specific categories rather than uniform underperformance across all four. Identifying the deficit requires category-level decomposition, not aggregate score tracking.

Quality measure denominators are the most frequent failure point. When an EHR exports quality measure data, it applies patient exclusion logic that can silently remove patients who should be in the denominator. A measure reporting 80% performance on a denominator of 45 patients may actually have 120 eligible patients—the other 75 were excluded due to miscoded diagnoses or encounter types. Smaller denominators increase score volatility and reduce the stability of performance rates across the performance year.

Promoting Interoperability requires specific attestation steps that many practices treat as annual paperwork rather than ongoing data collection. The PI category requires evidence of e-prescribing, CPOE usage, patient access through certified EHR technology, and health information exchange. Missing any required measure results in a zero for the entire PI category—a 25-point floor collapse that no amount of Quality or IA performance can fully compensate.

Improvement Activities are the most recoverable category. A practice earning zero IA credit almost always has staff performing qualifying activities that simply haven't been documented against CMS's catalog of 104 approved activities. Completing two medium-weight IA activities earns 15 full points, while one high-weight activity achieves the same result.

MIPS dashboards that show overall score hide the measure-level detail that determines whether improvement is achievable within the performance year. A practice at 71.2 points might be 2 points short of the threshold because of a single Quality measure where denominator expansion could lift performance by 5 percentage points. But aggregate dashboards don't surface that opportunity.

Standard reporting also hides the comparison between which measures are dragging the score versus which ones can be improved fastest. A measure at 45% performance with 200 patients in the denominator is very different from a measure at 45% performance with 12 patients. The first has a clear improvement pathway through care protocol changes. The second has high variance and limited improvement ceiling. Prioritizing improvement effort requires knowing both the performance gap and the denominator size for each measure.

Conduct a denominator completeness audit for each Quality measure you report. For each measure, pull the list of patients the EHR included in the denominator and compare against the clinical criteria in the measure specification. Practices routinely find 20–40% denominator expansion opportunity, which converts to meaningful performance rate improvement without changing clinical workflows at all.

Build a PI attestation checklist with quarterly checkpoints rather than treating PI as a year-end task. The e-prescribing and CPOE requirements need to be met across the full performance year, and many practices discover PI gaps only after the performance year closes—too late to remediate.

For Improvement Activities, assign a staff member to review the CMS IA catalog and match existing clinical workflows against qualifying activities. CMS small practice bonus adds 6 automatic points for practices with 15 or fewer clinicians—an often-overlooked boost that can close a 4-point gap without any additional reporting. MVP reporting options introduced for 2026 allow practices to report through a focused set of measures aligned to their specialty, often resulting in higher Quality scores for the same clinical performance.