MIPS Payment Adjustments: Find Errors Before 2027

A Medicare claim can be coded correctly, submitted cleanly, and paid exactly according to the remittance—and still deliver less revenue than the practice expected. The reason may sit outside the claim itself: a Merit-based Incentive Payment System payment adjustment attached to the clinician. For a busy billing department, that adjustment can look like another small contractual difference. Across a year of professional services, it deserves its own investigation.

October 2026 is a useful checkpoint because the MIPS performance year that determines 2027 payment adjustments is already over. Those adjustments generally reflect 2025 performance, not the quality-reporting work your team is doing now. The practical job is therefore different from improving a current score: verify the applicable result, establish whether any correction route remains available, and make sure January’s payments match what CMS actually assigned.

This is not another exercise in chasing every measure point. It is a revenue-control project connecting Quality Payment Program records, clinician identities, Medicare enrollment, reporting vendors, and remittance data. Practices that keep those functions in separate silos can miss an error twice—first when performance feedback becomes available, then when the resulting adjustment reaches their bank account.

1. Separate the performance calendar from the payment calendar

MIPS operates with a two-year gap between performance and payment. Work performed and reported for 2025 generally determines the adjustment applied to covered Medicare Part B professional services furnished in 2027. Performance during 2026 generally affects 2028 payments. A dashboard labeled with the current year may therefore be tracking a completely different revenue period from the one your finance director is forecasting.

Put both years on every internal report. “2025 performance / 2027 payment” is much harder to misread than “MIPS score.” Apply the same discipline to emails, vendor tickets, exported files, and meeting agendas. Otherwise, a reassuring answer about successful 2026 data collection can accidentally close an unresolved question about a 2027 penalty.

Also distinguish the CMS performance-feedback review from ordinary claims follow-up. A billing appeal does not replace a MIPS targeted-review request. Conversely, a correct performance score does not establish that a Medicare contractor applied the resulting adjustment correctly to a particular payment.

For the October worklist, obtain the relevant CMS feedback, identify its payment year, and check the published targeted-review deadline for that cycle immediately. Do not assume the window remains open simply because adjusted payments have not started. The correction calendar can close well before the first affected claim is paid.

2. Build the clinician-level exposure file

The unit of control is not just the practice. MIPS participation, scoring, and payment application depend on clinician and taxpayer identification details, along with the applicable reporting arrangement. A multispecialty group can contain clinicians with different eligibility histories and different payment consequences.

Start with a roster that reconciles your Medicare billing system to the Quality Payment Program records. Do not rely solely on a vendor’s list of people included in a submission. Someone absent from that list may still need an eligibility investigation; someone present may have a special status that changes how the result should be interpreted.

Use the following fields as a minimum working file:

Handle departures and acquisitions explicitly. A clinician who changes practices does not necessarily leave the consequences of prior performance behind. CMS has rules for assigning payment adjustments when billing relationships change. A new tax identification number is not, by itself, proof of a clean slate.

The enrollment team should validate billing relationships; the quality lead should validate participation and scoring; finance should estimate exposure. Give one person responsibility for resolving disagreements among those records. Without that owner, every department can have an internally consistent spreadsheet while the organization still has the wrong answer.

• Clinician name, National Provider Identifier, and relevant tax identification number.
• MIPS eligibility and any applicable exclusion or special participation status.
• Reporting arrangement, such as individual, group, or an applicable APM reporting pathway.
• Official final score, payment adjustment, performance year, and payment year.
• Employment changes, enrollment changes, and unresolved CMS or vendor cases.
• Expected Medicare professional-service payment volume for the affected payment year.

3. Budget the adjustment—not an imagined bonus

For the 2025 MIPS performance year, the performance threshold is 75 points. A final score below that threshold can produce a negative adjustment; a score at the threshold is neutral; a score above it can produce a positive adjustment. The maximum negative adjustment is 9%. Not every score below 75 receives the maximum reduction.

The positive side is where forecasts often become unreliable. MIPS positive adjustments are subject to budget-neutrality mechanics and scaling. A high score does not translate into an automatic positive 9% payment increase. Use the actual CMS-assigned payment adjustment when it is available, rather than converting score points into a percentage using an internal formula.

The separate additional adjustment for exceptional performance ended with the 2022 performance period, which affected 2024 payments. It should not remain embedded in a 2027 revenue model because an old spreadsheet still includes an “exceptional performer” line.

Define the payment base carefully, too. MIPS adjustments generally apply to Medicare payments for covered Part B professional services, not every dollar of Medicare-related revenue. Separately payable drugs, for example, should not simply be swept into the same forecast.

As an illustration, a negative 4% adjustment applied to a $100 Medicare professional-service payment would reduce that payment by $4. That is not the same as applying 4% to the entire allowed amount, including beneficiary liability. Have finance approve the calculation logic before the budget is locked.

4. Investigate the cost score beyond the reporting vendor

Cost deserves particular attention because it behaves differently from the measures a practice actively submits. Under the standard 2025 MIPS weighting, cost accounts for 30% of the final score, alongside quality at 30%, Promoting Interoperability at 25%, and improvement activities at 15%. Reweighting and participation circumstances can change that mix.

CMS calculates MIPS cost measures from Medicare administrative claims. A vendor can successfully transmit quality data while the practice receives a disappointing cost result. “The submission went through” therefore answers only part of the financial question.

Review which cost measures actually contributed to the score, whether applicable case minimums were met, and what the feedback shows about attributed patients or episodes. Attribution is measure-specific. It does not necessarily mean the clinician personally ordered every service whose spending appears in the calculation.

That distinction matters when physicians encounter hospital, post-acute, or specialist spending in their feedback. Some costs outside the office may properly fall within a measure’s design. Their presence alone is not evidence of a calculation error. Compare disputed results against the applicable measure specifications before escalating.

Use patient-level detail where CMS makes it available, with appropriate access controls. Look for a concrete discrepancy: an identity mismatch, an apparent attribution inconsistency, or a result that conflicts with the stated methodology. A targeted review needs a testable problem, not simply the observation that the attributed population was expensive.

5. Distinguish a correctable error from a disappointing result

CMS targeted review is a process for questioning the calculation of a MIPS payment adjustment. It is not a general opportunity to reopen the performance year, choose a better reporting strategy, or replace incomplete records after the fact. That distinction should govern both your internal investigation and the promises made to clinicians.

Potential issues worth investigating include submitted information that appears to have been evaluated incorrectly, an eligibility or special-status issue that was not reflected as expected, or a calculation that does not match the applicable rules. Whether relief is available depends on the facts and CMS’s review requirements.

For each issue, build a short evidence packet before opening a case. Include the relevant feedback, submission receipts, dated correspondence, identifying information, and a plain-language explanation of the discrepancy. Cite the specific program requirement or measure specification involved. Avoid sending a large folder and expecting the reviewer to discover the argument.

Check the actual annual deadline in CMS’s Quality Payment Program materials or authenticated account. As of an October planning exercise, the relevant window may already have closed. If it has, document that fact, contact the QPP Service Center about any remaining process that may apply, and avoid promising a score change.

Keep the case number, submission date, requested remedy, and final determination together. A vendor’s assurance that it is “working with CMS” is not a substitute for a traceable review record.

6. Close the handoff gap between quality and billing

Many practices have no formal handoff from the quality-reporting function to the billing department. The quality team receives a score, leadership hears that reporting is complete, and billers discover the payment consequence months later. Replace that informal sequence with a signed-off payment-adjustment register.

For each affected clinician, the register should identify the applicable adjustment, supporting CMS record, payment year, and any unresolved review. Give billing a read-only version and make finance the owner of the forecast. When CMS issues a revised result, update the register and preserve the earlier version rather than overwriting the history.

External partners need the same clarity. A practice using medical billing services should specify who verifies MIPS-related payment differences, who checks clinician identifiers, and who investigates an adjustment that does not match the register. Those duties are not automatically covered by a promise to submit clean claims.

Credentialing and enrollment staff also belong in the workflow when clinicians join, leave, or move between entities. Ask them to flag changes that could complicate payment attribution rather than asking them to interpret the entire MIPS program.

Finally, establish a response rule for missing information. If the official adjustment cannot be verified, label the forecast provisional. Do not silently substitute zero because the roster has a blank cell.

7. Test January remittances before posting rules hide the problem

The first 2027 remittances should be treated as a controlled test, not simply another posting batch. Select claims for clinicians with different verified adjustment outcomes and compare the payments with the official register. Focus on the applicable service dates and Medicare contractor guidance; a payment received in January is not automatically a payment for a 2027 service.

A remittance can contain several distinct payment effects. MIPS, sequestration, fee-schedule changes, beneficiary liability, and other adjustments should not be collapsed into one unexplained variance. Ask your posting team or software vendor to show how each component is identified and recorded.

Build a compact test set:

If the MIPS component is wrong, distinguish the source. An incorrect CMS assignment requires a different response from a contractor payment-application issue or an internal posting error. Preserve the remittance, claim identifiers, applicable adjustment record, and calculation used to identify the difference.

Do not automatically rebill the beneficiary for a MIPS-related Medicare payment reduction. The adjustment does not create a new patient obligation. A posting rule that transfers unexplained payer reductions to patient accounts can turn a revenue-reconciliation issue into a compliance problem.

• One or more clinicians with neutral adjustments, where available.
• Clinicians with positive and negative adjustments, where applicable.
• Claims for services furnished before and after the payment-year boundary.
• Claims involving recent clinician or billing-entity changes.
• Payments posted automatically and payments handled through manual exceptions.

8. Report the loss honestly instead of burying it in collections

A properly applied negative MIPS adjustment is not an unpaid claim balance waiting to be collected. It should not inflate collectible accounts receivable or enter the same queue as an avoidable claim denial. Yet it should remain visible as a reduction in Medicare professional-service revenue.

Create distinct reporting categories for the expected MIPS adjustment, a suspected payment-application error, and an internal posting error. This lets leadership separate an accepted program outcome from an operational failure that still requires correction.

It also protects performance measurement. A billing team should not be blamed for failing to collect a correctly applied statutory adjustment. Conversely, a favorable MIPS adjustment should not be presented as evidence that follow-up staff suddenly became more effective.

Practices engaging revenue cycle management services should define these treatments in reporting specifications. Monthly collections, net collection rate, contractual adjustments, and variance reports can tell different stories if each uses a different treatment of the same payment reduction.

For employed clinicians, reconcile the accounting treatment with compensation policies before disputes arise. Whether an adjustment affects a clinician’s compensation depends on the agreement and applicable rules—not on whichever posting category a staff member selected. Finance, legal counsel, and operations should agree on that interpretation.

9. Use the findings without confusing the next two years

The final step is to turn the investigation into a better operating system. A verified 2027 adjustment is largely a consequence of past performance. Current improvement work remains valuable, but it generally affects a later payment year. Keep remediation of historical errors separate from management of current performance.

Before the end of October, assign ownership of the clinician roster, retrieve the relevant official feedback, verify the review-window status, and identify material differences between CMS records and internal expectations. Escalate evidence-backed discrepancies promptly rather than waiting for the budget meeting.

Before year-end, approve the payment-adjustment register, test posting logic, and give finance a forecast that separates confirmed results from unresolved cases. Schedule a January remittance review with named participants from billing, quality, enrollment, and finance.

For ongoing performance, examine the actual weakness behind the score. Missing submission evidence calls for better controls. Confusing attribution calls for education and measure analysis. A recurring coordination problem may require clinical changes rather than more aggressive billing follow-up. One generic “improve MIPS” action item will not address all three.

The goal is straightforward: every Medicare payment difference should have an explanation, an owner, and the correct accounting treatment. MIPS stops being an obscure quality-program score when the practice can trace it from CMS feedback to a clinician, a payment year, and an actual remittance.