Understanding Your 2024 MIPS Feedback Report and Preparing for Year-End Requirements

Understanding Your 2024 MIPS Feedback Report and Preparing for Year-End Requirements

By Kimberly Bailey

September 2025 is an important month for all Merit-based Incentive Payment System (MIPS) participants. The Centers for Medicare and Medicaid Services (CMS) will release the 2024 MIPS Feedback Reports, which provide your final score for the performance year. Along with the report, the Targeted Review window will open.

What is a Targeted Review?

A Targeted Review is your opportunity to dispute your MIPS final score if you believe there was an error in how it was calculated. This process is time-sensitive — you will have 30 days from the release of the report in September to submit your request.

If you miss this window, your score will be considered final.

Why Does This Matter?

Your final MIPS score directly affects your Medicare reimbursement rates. In October 2025, CMS will publish the payment adjustments that will impact your 2026 Medicare payments. A lower score could mean a penalty, while a higher score could result in a positive payment adjustment.

Key Year-End Compliance Reminders

As we enter the final 180 days of the Promoting Interoperability (PI) reporting period, there are a few critical requirements to keep in mind.

1. Prescription Drug Monitoring Program (PDMP) Requirement

If a provider prescribes at least one controlled substance during the reporting year, they must check their state’s Prescription Drug Monitoring Program (PDMP) database or use an integrated electronic health record (EHR) connection.

• Group Reporting: If one physician meets the PDMP requirement, it satisfies the measure for the entire group.

• Individual Reporting: Each provider who has prescribed at least one controlled substance must meet the PDMP requirement independently to report the PI category successfully.

Failing to meet this measure can prevent you from receiving credit for the PI category.

2. Security Risk Assessment (SRA)

CMS requires that you perform and document a Security Risk Assessment annually. This ensures your systems meet HIPAA security requirements and that patient data is adequately protected.

3. SAFER Guide Completion

The Safety Assurance Factors for EHR Resilience (SAFER) guides must be reviewed and completed to ensure your EHR systems are optimized for patient safety.

4. Annual HIPAA Training

Do not forget that all workforce members must complete their annual HIPAA training by December 31, 2025.

Action Steps

• September 2025: Review your MIPS Feedback Report immediately upon release.

• Within 30 days: Submit a Targeted Review if you find discrepancies.

• Before Year-End: Complete PDMP checks, SRA, SAFER guide, and HIPAA training.

Proactive monitoring of your MIPS score and timely completion of these requirements can protect your reimbursement and compliance standing.

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