When it comes to the Merit-based Incentive Payment System (MIPS), the sheer volume of information can feel like a mountain of paperwork waiting to fall over. It’s hard to know where to start, much less how to keep your practice from getting buried in shifting requirements and looming CMS penalties.
At Ingenious Med, we believe that high-level compliance should be a seamless part of your workflow, not an administrative burden. That’s why we’ve built our platform to do the heavy lifting—offering real-time tracking, specialty-specific measure sets, and a CMS-approved registry that’s completely free for our clients. From deep-dive webinars to automated performance alerts, we’re here to make sure you aren’t just participating in MIPS, but actually winning at it.
To bring some much-needed clarity to the process, we sat down with our MIPS Program Manager, Stephen Besch, who has been an industry expert for almost 20 years. We picked his brain on everything from the basic “MIPS 101” fundamentals to the technical logic that keeps our submission success rate at a perfect 100%.
“Making successful MIPS participation as simple as possible for physicians and administrators is a continual challenge that I enjoy meeting.”
1. To start off, how did you find yourself in the world of regulatory compliance? It’s a complex field—what keeps you energized when you’re turning these ever-changing rules into stable software?
“When the Centers for Medicare & Medicaid Services (CMS ) developed the Physician Quality Reporting Initiative (PQRI) in 2007, I recognized Ingenious Med’s platform would be in a powerful position to identify reportable patients and collect performance data from clinicians at the point of care. The evolution of that program through PQRS and, finally, into MIPS added complexity with each passing year. Making successful MIPS participation as simple as possible for physicians and administrators is a continual challenge that I enjoy meeting.”
2. If you had to pick a ‘MIPS Superpower’ that helps you thrive in a regulatory environment, what would it be? Whether you’re a ‘regulatory decoder’ or a ‘logic architect,’ how does that skill actually make life easier for our clients?
“The ability to digest a complex list of criteria and distill it down to a few simple key points is probably my strongest contribution to the program. The more CMS attempts to simplify the system, the more complicated it gets. Figuring out what’s relevant to our users and what isn’t, then explaining a simplified path to success for people who don’t study MIPS as a full-time job provides a huge benefit to our clients.”
“Based on their combined scores, a clinician or group might receive a payment adjustment for their Medicare charges of plus or minus 9%.”
3. For those who might be new to this, can you give us a high-level overview? What exactly is MIPS (Merit-based Incentive Payment System), and why is it so important?
“MIPS is the evolution of CMS programs aimed at increasing quality of care while decreasing cost. There are 4 categories in which clinicians are evaluated: Cost, Quality, Improvement Activities, and Promoting Interoperability. Some of these categories are evaluated automatically by CMS, while others require the clinician to actively submit data to CMS for evaluation. Based on their combined scores from these categories, a clinician or group might receive a payment adjustment for their Medicare charges of plus or minus 9%. These payment adjustments are applied to the calendar year that follows 2 years after the evaluation period.”
4. We hear a lot about ‘quality measures.’ In plain English, what are they actually looking for, and how do they impact a clinician’s day-to-day?
“Some quality measures are designed to determine if clinicians are following the “gold standard” in providing medical care for specific conditions, while others attempt to identify scenarios in which treatments or procedures are performed that are no longer considered relevant to a patient’s condition. If a patient encounter meets the reporting requirements of a measure the clinician has opted to report for the performance period, they are required to document additional information to indicate what actions they did or didn’t perform in relation to the quality measure. Their answer may indicate they met performance goals related to the measure, they failed to meet performance goals for the measure, or the patient was excluded from the measure population for some reason.”
5. On a practical level, how does a clinician or an admin actually keep track of these measures without getting buried in paperwork?
“Each charge that is saved in Ingenious Med is evaluated for applicability of any measures the client has elected to track. If the encounter is reportable for one or more quality measures, we present a questionnaire to the clinician to collect their performance results for the measure. The performance results are viewable in a summary report that allows administrators to monitor cumulative performance for each clinician on each quality measure. An encounter-level report is also available to identify specific instances that may need corrections to the performance results.”
6. Do you see MIPS compliance as a core feature of our product? How did that outlook influence Ingenious Med’s software development?
“With the looming specter of a 9% Medicare penalty, successful MIPS participation is a critical step in protecting revenue for our clients. One of Ingenious Med’s core design tenets is the protection of revenue, so I consider our MIPS functionality fundamental to the optimal design and use of our software.”
“Understanding how the Specialty Measure Sets could improve MIPS scores created huge benefits for our client base.”
7. There are hundreds of measures out there. How do we help a client find the ones that actually fit their specific patient population instead of just handing them an overwhelming list?
“Most hospitalists and other inpatient clinicians share a very similar billing pattern. The Hospitalist Specialty Measure Set is going to contain the only quality measures relevant to their clinical scope of practice. For groups with billing patterns that deviate from this standard admit/follow-up/discharge pattern, we can analyze their billing history and compare it to reportable scenarios for any measure in the MIPS system. That allows us to hone in on specific measure options available to that particular practice.”
8. Beyond just tracking data, how does Ingenious Med actually simplify the reporting process for complex groups?
“The performance results are viewable in a summary report that allows administrators to monitor cumulative performance for each clinician on each quality measure. An encounter-level report is also available to identify specific instances that may need corrections to the performance results. When the billable encounter is exported from the system to the billing software, the quality reporting data associated with that encounter is also transmitted. That simultaneous transmission satisfies the reporting requirements for the claims-based reporting option. Ingenious Med clients also have the option to submit their performance data through IM’s qualified registry service at the end of the year. The registry provides a reporting option for groups larger than 15 clinicians (who aren’t allowed to use the claims-based reporting system), as well as a failsafe submission option for any small practices (15 or fewer clinicians in a single TIN) who want to be sure their performance data reaches CMS, since the claims-based reporting process has proven unreliable due to issues introduced by many billing applications.”
9. Can you think of a specific ‘aha!’ moment where a small tweak in the software logic ended up making a huge difference in a client’s score or their overall experience?
“Understanding how the Eligible Measure Applicability (EMA) tests and, later, the Specialty Measure Sets could improve MIPS scores for Hospitalists while reducing their reporting burden created huge benefits for our client base. Many clinicians and administrators are still unaware of those benefits, but we continue to educate our clients to help more participants maximize their success.”
10. Which MIPS performance category is the most challenging to automate, calculate, or report on within a SaaS environment, and how do we help customers with this performance category?
“The Quality category is still the most important to inpatient clinicians, since it represents 55% of their total MIPS score. While the implementation of our data collection and reporting tools are relatively straightforward, the category remains challenging to most inpatient practices because, so few measures are available to report, and the measures that are available are capped at 7 points. But those are limitations of the MIPS system as it exists today, not limitations of the IM system.”
MIPS Data Accuracy: How We Achieve 100% CMS Submission Success
“In our 15 years of qualified registry participation, Ingenious Med has maintained a 100% data submission success rate with CMS, while simultaneously maintaining a 0% data error submission rate.“
11. Looking back at your time as Program Manager, what’s the biggest lesson you’ve learned about keeping data clean and dealing with the impact of new regulations?
“Changes in the various quality reporting programs can appear virtually unannounced. We have to scrutinize all documentation and understand subtle statements from CMS in order to identify the most important changes. Largely irrelevant changes to the program can be identified clearly and repeatedly by CMS while more critical changes may be mentioned only in passing or not at all.”
12. There’s reading the MIPS rulebook, and then there’s actually coding it into Ingenious Med’s software. What’s the hardest part about translating those government rules into functional software?
“Recognizing which quality measures are actually applicable to our client base is important. Measure titles can be misleading and can result in the selection of measures that won’t contribute to reporting success. Our analytical tools allow us to review an enormous pool of clinical data to zero in on the specific quality measures that will be the most beneficial to our clients.”
13. How does your work as a Systems Analyst directly support the successful design and implementation of MIPS functionality within our product?
“Developing the flow of the quality measure logic is a very step-wise process. Being able to compare our measure flows directly to the CMS specs is important to ensuring data is captured appropriately. The ability to analyze large pools of measure data in preparation for submission to CMS through our registry service is also a critical factor in maintaining our 100% submission success record, with a 0% error transmission rate.”
14. How does Ingenious Med ensure successful, real-time calculation of MIPS scores for our clients?
“Our registry engine is a powerful tool that processes a tremendous amount of data. It compiles the data into a format that we’re able to analyze with a separate set of tools for cross-validation prior to submission.”
15. Accuracy is everything here. What kind of checks and balances do you have in place to make sure the logic is 100% correct before it ever reaches a client?
“We design the measure logic to match the individual measure flow charts provided by CMS. Those are double-checked by the Development team before the measures are constructed, then triple-checked by the QA department to make sure the application behavior matches the documented measure flows precisely.”
16. How far out are you planning next year’s rules? And more importantly, how do we make sure our clients can see their data as they go, rather than waiting for a surprise at the end of the year?
“CMS historically releases the new measure specifications very close to the end of the year. We reserve bandwidth on our technical teams so we can dive into the work of updating the measure definitions within our system as soon as CMS finalizes those details. Our application offers powerful reporting tools that allow administrators to monitor the performance rates of their staff on a daily basis. Reports are available to assess this both at a glance, as well as deeper dives into the individual encounter level data when necessary.”
17. When that massive CMS ‘Final Rule’ drops every year, what are the first three things you do to turn hundreds of pages of rules into a roadmap for the engineers?
“By the time the rule is finalized each year, we’ve already been tracking the potential changes through the proposed rule documentation for several months. If there are changes that will potentially require programmatic shifts in our software, we will have contingency plans already in place and ready for activation if CMS finalizes those changes. Since the quality reporting program is entering its 19th year in 2026, changes that might require reconstructing our application logic are unlikely. The most common changes are modifications to individual measure specification and updates to the participation requirements for clinicians. Our system is built in a way that measures, specification updates are straightforward, and we offer a series of webinars each December to inform our clients about any relevant changes to their participation requirements.”
Staying in the Clear – Deadlines and the Registry Edge
“Having the data and later finding they don’t need it is better than finding out later that they need it and don’t have it.”
18. If a client does just one thing at the start of the year to check their eligibility, what should it be?
“Most clinicians will easily surpass the low volume thresholds and will be designated as full participants in MIPS. Clinicians with extremely low volumes (locums, for example) should check their status on the CMS participant lookup tool on a regular basis. Unfortunately, their participation status may change over the course of the year, as CMS updates their eligibility based on four separate “snapshots” of their accumulated volume. In the end, capturing performance data from the beginning of the year on the expectation that they may become eligible participants is the safer bet. Even if they don’t ultimately reach the low volume thresholds, they can submit their performance data voluntarily and receive a feedback report from CMS, without any risk of incurring penalties.”
19. Why use a Registry? What makes that path better than just reporting through an Electronic Health Record (EHR) or via claims?
“CMS no longer accepts claims-based reporting from groups with more than 15 NPIs billing under their Tax ID Number, so that option is off the table for many practices. EHR reporting is largely invisible to clinicians and, while that can be preferable for the clinicians, it can result in lower performance rates since there are no reminders from the system to perform the quality measure actions in applicable cases. Ingenious Med’s system will prompt clinicians for a response to applicable quality measures, which can serve as a reminder to actually perform the measure action and improve performance rates. Using IM’s qualified registry service to submit performance data at the end of the year not only guarantees accurate performance data is reaching CMS, but it also gives the practice the flexibility to edit their MIPS data throughout the course of the year to keep it as accurate as possible.”
The Ingenious Med Registry is FREE!
Most 3rd-party registries charge hundreds of dollars per clinician. But if you meet our CMS-approved registry requirements, we offer submission at no additional cost. High MIPS scores + zero submission fees = an easy choice.
20. We often hear questions about deadlines. What specific date should our clients consider the absolute final cutoff for data submission each year?
“There are two key deadlines related to registry reporting through Ingenious Med. November 30th is our annual cutoff for opting into registry submission for that year’s data. Once opted into the registry, January 15th of the following year is our typical deadline to complete the administrative configuration tasks on the client side, which prepares their data for processing and submission through the registry. These dates (and the administrative tasks required) are fully explained in our yearly registry orientation webinars, which usually take place during the first half of October.”
21. If our readers walk away with just one key takeaway about our MIPS capabilities, what should it be?
“Attend our free webinars in December to learn what’s changing within the MIPS program in the coming year and what strategies are recommended to maximize your scoring. These sessions will also clearly describe the best practices within IM to support your team’s success.”
Ready to take the stress out of MIPS? Reach out to Ingenious Med for help!
Navigating MIPS doesn’t have to be a solo trek through a mountain of CMS paperwork. Whether it’s through our automated tracking or our end-of-year registry support, the goal is to keep your revenue protected and your focus where it belongs: on the patients. If you’re feeling the year-end crunch or just want to make sure you aren’t leaving money on the table, keep an eye out for those December sessions—they’re the best way to turn a complex mandate into a straightforward win for your practice.
Don’t wait until the end of the year to find out where your performance stands. See how our platform turns complex regulatory requirements into a streamlined, real-time workflow that protects your revenue.
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