‘It takes a village to do well in MIPS’: Holly Black on protecting Medicare revenue in 2026

Often called a "MIPS geek guru," Holly Black, product manager for regulatory affairs and compliance at Sightview Software, has spent more than 35 years in the ophthalmology field helping practices survive every acronym Medicare has thrown at them, from meaningful use and the physician quality reporting system (PQRS) to today's Merit-based Incentive Payment System (MIPS). She works directly with ophthalmology and optometry organizations on MIPS strategy, scoring optimization and Centers for Medicare & Medicaid Services (CMS) reporting.

MIPS, which is part of the Quality Payment Program, scores clinicians across four categories — quality, promoting interoperability, improvement activities and cost — then adjusts Medicare payments based on a composite score of 0 to 100.

For busy specialists, missing a deadline, choosing the wrong measures or overlooking a documentation tweak can easily translate into a negative payment adjustment.

Medical Economics spoke with Black about what's new for 2026, how MIPS Value Pathways (MVPs) are playing out in real practices, and what small and mid-sized groups can realistically do with just a few hours a month to protect their revenue.

This interview has been edited for length and clarity.

What are the most important MIPS changes in 2026, and where are you seeing practices struggle?

Holly Black: I like to break it down by category, because that is usually easiest.

For the quality category, there are some new measures, but nothing major. The biggest thing is for large practices, which are practices of 16 physicians or more. CMS has removed the 3-point scoring floor. That has a huge impact, because those practices can now get fewer points if they do not meet the 75% data completeness criteria. Before, they would at least get a minimum of 3 points, but that is no longer true for large practices. Small practices still get that 3-point floor.

For the promoting interoperability category, the biggest change is around the security risk analysis. It has always been a requirement for the category, and in the past you could simply attest yes, that you completed a security risk assessment for your electronic health record (EHR) product. Starting this year, not only do you have to report that you completed that assessment, you must also have a documented plan of action in place for any issues that are found. So it is not just a yes-or-no answer anymore.

In terms of struggles, what I often see is that practices do not pay attention to quality measures that are topped out, which gives them a lower performance score. They need to focus on those measures that are topped out, avoid them if they can, and be careful with measures that have very high benchmarks. Even if a measure is not topped out, when you have those high benchmarks, you pretty much need 100% performance to get a significant number of points. Practices often do not take the time to look at that, and it costs them in the end.

They also need to be aware of the documentation requirements for the SAFER Guides, which are part of the promoting interoperability category. The SAFER Guides were updated last year, so practices need to use the 2025 SAFER Guides instead of the previous 2016 version.

We’re already a couple of months into 2026. What are one or two adjustments practices can still make now so they are not scrambling at the end of the year?

The good news is that at this time of year, it is still early enough that you can make changes that will have a significant impact.

The biggest thing I recommend is to create a MIPS team. You know the old saying, “It takes a village to raise a child.” I tell my clients it takes a village to do well in MIPS. Create that team. Have a point person look at the rules, and then get your team involved. Help them understand the importance of the workflows and what it will mean, not only to the practice, but how it trickles down to them. It really makes a difference in getting the team engaged and not leaving it all on one person.

The other big piece is to run your reports. Run your internal reports and check how you are doing. Even if you do not have time to do it monthly, doing it quarterly will make a huge difference and will prevent the stress and scrambling at the end of the year to correct mistakes that have been made all year long. If you are doing it throughout the year, your team gets in the habit of knowing what to do, and you do not have those corrections to make at the end.

Also, take a few minutes to know your key dates and deadlines. A very common example is mapping deadlines with a registry. Many practices use a registry for MIPS reporting. Those registries have mapping deadlines, so if you see a discrepancy in how they are mapping data from your EHR, you can request that a measure be remapped — but there is a deadline, and it is usually Sept. 30. You do not want to miss that.

The same goes for your MIPS attestation. Right now we are in the window for MIPS attestation for 2025, which ends March 31. You want to make sure you get everything done and completed before that deadline, or you cannot report.

CMS has been pushing MIPS Value Pathways, or MVPs, as the future of the program. As of 2026, how is that playing out, and what does it mean for specialists compared with staying in traditional MIPS?

As of this year, you have the option to report through an MVP. If you opt in and report both traditional MIPS and an MVP, CMS will take the higher of the two scores, and that will be the score your payment adjustment is based on.

So now is the time to start looking at MVPs and maybe opting in to see how you do and get ready for it. CMS has not set a finalized date yet, but they are looking at MVPs becoming mandatory, possibly as soon as 2029.

Many registries offer both traditional MIPS and MVP dashboards, so you can look at both and see what makes sense.

For specialties, the good thing about MVPs is that they are geared toward specific specialties. This year, CMS added six new specialty measure sets for diagnostic radiology, interventional radiology, neuropsychology, pathology, podiatry and vascular surgery. There are many more.

With MVPs for quality measures, you are required to report on four measures instead of six, and those measures are specific to your specialty. That is helpful. Where it can become difficult is in subspecialties. In ophthalmology, for example, we have subspecialties like oculoplastics, and there is no ophthalmology oculoplastics MVP, so it is very difficult for someone in that subspecialty to find four measures that are specific to their work. When you get into a very specialized practice, you can have some difficulty with MVPs.

How has specialty MIPS reporting changed over the past few years with MVPs entering the picture, and what can other specialties learn from that?

What we have found this year, with practices opting in for MVPs, is that most of those practices are scoring almost exactly the same as they do under traditional MIPS. Some are a couple of points higher, but for the most part, we are not seeing huge fluctuations.

That is the good news for any practice. If we are seeing that in ophthalmology, hopefully, you will see that across other specialties as well. CMS has set up these MVPs to make reporting a bit easier, again because you are only reporting four quality measures instead of six. Instead of trying to find six good ones, you are only finding four good ones to worry about.

The takeaway right now is to look at the MVPs and focus on the measures specific to your practice and your patient demographics. If you do that, that is how you will get higher performance scores.

MIPS is not new anymore — the program really started in 2017. This far in, what compliance or reporting mistakes are you still seeing that directly cost practices money, and how can physicians and administrators catch those issues before the end of 2026?

We still see some of the same things. Missing reporting deadlines is one.

As I mentioned earlier, you have to keep on top of mapping if you use a registry. Sometimes it is not that your practice is using an incorrect workflow; it is that, for whatever reason, the data being transferred from your EHR to the registry is not coming over correctly, and you need the registry to remap the measure. Knowing those deadlines is huge.

The same is true if a practice is switching EHRs during the year. You need to be aware of the deadlines to add the new EHR to the registry, because that can be a big issue. Or if you are using a registry for the first time and integrating an EHR, if you wait until the end of the year, you may not have a dashboard to view to know how your measures are doing. You want to do those kinds of things early.

You also need to watch your Promoting Interoperability reporting. Make sure you complete the security risk analysis and the SAFER Guides as required. The focus for Promoting Interoperability is sending health information — that communication is the core of the category, and that is where you want to focus your attention.

Finally, a big mistake is ignoring data validation and failing to meet the 75% data completeness threshold. All of this is easily avoidable if you take a few moments, at least quarterly — preferably monthly — to review your information. Make sure you are on track, that workflows are being done, and that you are tracking data correctly.

Very often with MIPS, everything gets put on the practice administrator. But practice administrators are not usually in the clinic, so they are not doing the workups and do not always know how data is being entered into the exam. If you create a team that includes your practice administrator, a physician and your clinical team lead, you have more than one person involved, and you have different levels of knowledge to make sure you are doing the best you can.

How much does the way clinicians document in the EHR now show up in MIPS performance?

It has become very important. Last year, CMS stopped allowing manual data submissions. So you pretty much have to have an EHR to report MIPS and get anything beyond a negative payment adjustment.

The way you capture data in your EHR is crucial for high scores. Inefficient workflows lead to missing data and reporting errors. You want to use standardized, structured fields rather than free text. The more you can automate your system, the better it will be for your performance scores, and it is actually easier in a clinical workflow because you can click a button for pre-populated data rather than typing out sentences.

Proper integration of MIPS into daily tasks will also improve performance. And patient engagement through portals and communication tools, especially when those are automated, will increase your performance for key measures in the Promoting Interoperability category.

For practices that are already short-staffed, what strategies can they implement to protect Medicare revenue from MIPS penalties without piling on administrative burden?

Use your EHR to its full capability and use those preset data input options. Understand your category weights, and then validate and double-check data for accuracy.

If you are using a registry — or even if your EHR has its own registry — do not assume everything is fine. Double-check it. Look at the data on the registry or dashboard and make sure it is pulling in correctly, because there can be errors. That is where a lot of practices struggle: they do not look during the year, and at the end of the year, they are scrambling, saying, “This does not look right. Why not?” At that point, it is kind of too late.

Focus on your highest weighted categories, which are quality and cost. Those are each worth 30% of your total MIPS score.

If a practice only has a few hours each month to dedicate to MIPS planning, what should be at the top of the priority list?

Choosing the right measures.

You want to focus on measures that are specific to your practice and your patient demographics. If you only have a couple of hours a month, focus on tracking those measures and making sure workflows are correct. If you are doing the work but workflows are not being done correctly, review them with the team.

Before I worked with this company, I worked for a medical practice as their MIPS coordinator and staff and physician trainer. I would spend maybe five hours a month, at most, looking at MIPS. I focused on making sure the quality measures on my dashboard were being mapped correctly. If they were mapped correctly, but we were not doing well, I would look at the workflow and say, “This is what we are doing wrong,” then take it back to the team.

A quick meeting over lunch or at the end of the day to say, “We are not doing well on this measure; here is what we need to do to improve it,” goes a long way. It only takes a few hours a month, and that is the easiest and fastest way to get the performance score up.

Is there anything we have not covered that practices should keep in mind as they plan their MIPS strategy?

Make sure you check the CMS website — qpp.cms.gov. They have everything you need to know about MIPS reporting. There is a lot of information, but you can drill it down to what you want to look at. You can look at specific measures to see if there were any changes.

Remember that even if a MIPS measure did not change and is no longer topped out or anything like that, there may be small nuance changes in the requirements. Do not assume that what worked last year will work this year. The category where we see the biggest impact is improvement activities. Often, the activities themselves do not change, but the wording or the description of the documentation requirements does.

One year you do fine, then the next year you say, “I can report on this again,” but the documentation requirements are different, and you [may not be] prepared. Once you pick an improvement activity, take a few minutes to review it and ensure you understand the documentation requirements.