Quality Payment Program Small Practices Newsletter: September 2025
Quality Payment Program Small Practices Newsletter: September 2025
The Quality Payment Program (QPP) Small Practices Newsletter is a monthly resource that provides small practices (15 or fewer clinicians) with program updates, upcoming QPP milestones, and resources to support their continued participation and success in QPP. We send this newsletter on the second Tuesday of each month.
Please share this newsletter with your fellow clinicians and practice staff and encourage them to sign up to receive this monthly resource.
At-a-Glance: Required and Recommended Activities for Successful Participation in QPP
Each month, we share required and recommended activities for small practices to support their successful participation in QPP. The activities follow a rolling quarter approach, letting you see activities for the previous month, the current month, and the following month.
The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2024 performance year.
Your 2024 final score determines the payment adjustment you’ll receive in 2026.
2026 MIPS payment adjustments will be available in approximately one month.
How Do I Access Feedback?
Sign in to the Quality Payment Program (QPP) website using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) system credentials; these are the same credentials that allowed you to submit your 2024 MIPS data.
Click “View Feedback” on the home page and select your organization (Practice, Alternative Payment Model (APM) Entity, Virtual Group).
Practice representatives can access individual, subgroup, and group feedback.
Third party representatives can’t access final feedback or payment adjustment information.
If you don’t have a HARP account or QPP role, please refer to the Register for a HARP Account (re: HARP account) and Connect to an Organization (re: QPP role) documents in the QPP Access User Guide (ZIP, 4MB) and start the process now.
Medicare Shared Savings Program Accountable Care Organizations (ACOs)
Medicare Shared Savings Program ACOs are encouraged to identify at least one individual within your ACO who can obtain a HARP account with the Security Official role; additional individuals may request the Staff User role. ACO individuals can create and manage their HARP account and QPP access in the ACO Management System (ACO-MS).
Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at SharedSavingsProgram@cms.hhs.gov or 1-888-734-6433 (Option 1).
Representatives of Shared Savings Program ACO Participant Taxpayer Identification Numbers (TINs) and practices with clinicians receiving their APM Entity’s final score won’t be able to access the APM Entity’s performance feedback unless they’ve been approved as a staff user for the APM Entity.
Individual clinicians, groups, subgroups, virtual groups, APM Entities (including Shared Savings Program ACOs), designated support staff and authorized third party intermediaries may request that CMS review their MIPS final scores through a process called targeted review.
When to Request a Targeted Review
If you believe there’s an error in the calculation of your MIPS final score, you can request a targeted review now.
The targeted review period will be open for approximately 60 days. Beginning with the 2024 performance period, targeted review opens with the release of final scores and will close 30 days after the release of MIPS payment adjustments. We’ll announce the release of MIPS payment adjustments through the QPP listserv in approximately one month.
For example:
Data were submitted under the wrong TIN or National Provider Identifier (NPI).
You have Qualifying APM Participant (QP) status and shouldn’t receive a MIPS payment adjustment.
Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances.
Note: This isn’t a comprehensive list of circumstances. If you have questions about whether your circumstances warrant a targeted review, please contact the QPP Service Center by phone at 1-866-288-8292 (TRS: 711) or by email at QPP@cms.hhs.gov.
How to Request a Targeted Review
To access your MIPS final score and performance feedback and request a targeted review:
Sign in using your HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed you to submit your 2024 MIPS data.
Click “Targeted Review” on the left-hand navigation.
CMS generally requires documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required. If the targeted review request is approved and results in a scoring change, we’ll update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Please note that targeted review decisions are final and aren’t eligible for further review.
Targeted Review Resources:
2024 Targeted Review User Guide (PDF) – Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review.
Key QPP policies that we are proposing in the CY 2026 Medicare PFS Proposed Rule include:
Introducing 6 new MVPs for the 2026 performance year that are related to diagnostic radiology, interventional radiology, neuropsychology, pathology, podiatry, and vascular surgery.
Allowing multi-specialty small practices to continue reporting MVPs at the group level (i.e., not requiring multi-specialty small practices that want to report an MVP to do so at the individual or subgroup level).
Introducing a 2‑year informational-only feedback period for new cost measures, allowing clinicians to receive feedback on their score(s) and find opportunities to improve performance before a new cost measure affects their MIPS final score.
Maintaining the current performance threshold policies, leaving the performance threshold set at 75 points through the 2028 performance year.
Introducing Qualifying APM Participant (QP) determinations at the individual level, in addition to existing determinations at the APM entity level.
CMS encourages you to submit comments on these proposals. You must officially submit your comments in one of the following ways:
Electronically– You may submit electronic comments here.
Express or overnight mail– You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS‑1807‑P, Mail Stop C4‑26‑05, 7500 Security Boulevard, Baltimore, MD 21244‑1850.
Regular mail– You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS‑1807-P, P.O. Box 8016, Baltimore, MD 21244‑8016. At this point, there may not be sufficient time for mailed comments to be received prior to the end of the comment period.
Please note: FAX transmissions won’t be accepted.
The 60‑day comment period for the CY 2025 PFS Proposed Rule is open until 5 p.m. ET on September 12, 2025.
CMS identified that the Acute Kidney Injury Requiring New Inpatient Dialysis (AKI) measure warrants exclusion from our calculation of MIPS eligible clinicians’ scores under the cost performance category for the calendar year (CY) 2024 performance period/2026 MIPS payment year in accordance with our measure exclusion policy at 42 C.F.R. § 414.1380(b)(2)(v)(B).
Therefore, the AKI measure won’t be included in the calculation of MIPS eligible clinicians’ scores under the cost performance category for the CY 2024 performance period/2026 MIPS payment year.
The following resources contain additional information about the cost measures that will be calculated and reported under the cost performance category, as well as the AKI measure:
Have you submitted PY2024 data to the Quality Payment Program (QPP)? If so, we want to hear from you!
The goal of this feedback survey is to help CMS better understand the experiences of QPP participants who have submitted Performance Year (PY) 2024 data. Your responses will help CMS identify what’s working well and where improvements can be made in the MVP reporting process.
The survey should take no more than 15 minutes to complete. It is conducted by independent contractors, and all responses are confidential and voluntary. Results will be reported in such a way that no individual, group, or entity can be identified. Your decision to participate will not affect any current or future determinations.
Your feedback is essential to understand how we can best serve QPP participants. Eligible clinicians who complete this survey may receive an IA credit. If you have any questions please reach out to qppuserresearch@cms.hhs.gov.
Interested in participating in upcoming research with the QPP Human-Centered Design Team? Fill out this survey to be added to our QPP user research contact list.
CMS has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in the designated affected counties of Texas for the 2025 performance period.
MIPS eligible clinicians in these areas will be automatically identified and will have all 4 performance categories reweighted to 0% during the data submission period for the 2025 performance period (January 2 to March 31, 2026).
This will result in a score equal to the performance threshold, and they’ll receive a neutral payment adjustment in the 2027 MIPS payment year.
Share your feedback on what you like most about the Small Practices Newsletter, what can be improved, and/or what topics you would like to see addressed. Please include “Small Practices Newsletter” in the email subject line.
Contact the QPP Service Center by email at QPP@cms.hhs.gov, by creating a QPP Service Center ticket, or by phone at 1‑866‑288‑8292 (Monday – Friday, 8 a.m. – 8 p.m. ET).
To receive assistance more quickly, please consider calling during non-peak hours — before 10 a.m. ET and after 2 p.m. ET.
People who are deaf or hard of hearing can dial 711 to be connected to a Telecommunications Relay Services (TRS) Communications Assistant.
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