The MIPS 9% hit: how Medicare actually takes it, and how not to walk into it
If you are MIPS-eligible and you submit nothing, CMS can cut Medicare Part B professional payments by the statutory maximum: 9% for a full payment year, two years later. That is not a rumor. It is how the Quality Payment Program is written. ClearBilling keeps this on the same US team that bills your AA, QZ, and QS claims.
What the 9% is
MIPS (Merit-based Incentive Payment System) adjusts Medicare Part B payments for covered professional services. The statutory maximum negative adjustment is 9%. It has been 9% since the 2022 payment year. It applies to the payment year, not as a one-time fine.
MIPS is budget-neutral. The penalty pool funds the bonuses. The bonus has been small. The money is not chasing a 1% upside. It is not taking a 9% haircut on every Medicare professional claim for a year because nobody submitted.
The two-year lag
Performance year 2026 sets the adjustment on 2028 dates of service. Missing this year is a 2028 problem with your name on it. Confirm the year in front of you on qpp.cms.gov. We do not invent CMS calendars.
The 75-point line
CMS has finalized a 75-point performance threshold for the 2026 performance period / 2028 payment year (and has kept that level through later years in the same rule). A final score of 75 is neutral. Below 75, the cut slides. At or below 18.75 (one quarter of the threshold), you take the full -9%. Submitting nothing when you are eligible is how groups land there.
Anesthesia specifics
Not every CRNA or anesthesiologist is MIPS-eligible. Low-volume clinicians can fall out. Qualifying participants in Advanced APMs can fall out. Everyone else who bills enough Medicare Part B professional services can take the hit. Check the QPP Participation Status Tool for each NPI / TIN, then check again when CMS posts final eligibility.
Hospital-based and non-patient-facing special statuses are common in anesthesia and often reweight Promoting Interoperability. That is not an excuse to skip Quality and Improvement Activities. It is a reason to report the categories that still count.
What a biller should actually do
Know who is eligible. Pull what the anesthesia record already supports. Keep the submission calendar from slipping. Do not let a factory 'forget quality' while they chase claims. We will not guarantee a positive payment adjustment, and we will not put a fake 100 on a file. Follow current CMS QPP rules for the year you are in.
FAQ
Straight answers for practices comparing anesthesia billing companies.
Is the maximum MIPS penalty really 9%?
Yes. The statutory maximum negative payment adjustment is 9% of Medicare Part B covered professional services in the payment year. Eligible clinicians who submit nothing typically score zero and take that full cut.
Does a 2026 performance year hit 2026 payments?
No. There is a two-year lag. 2026 performance adjusts 2028 payments.
If we are hospital-based, can we ignore MIPS?
No. Hospital-based and non-patient-facing statuses often reweight Promoting Interoperability. Quality and Improvement Activities can still count. Check status per NPI / TIN.
Will ClearBilling promise a MIPS bonus?
No. Bonuses are tiny and funded by other people's penalties. The job is not taking the 9% hit.
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