What ACOs Need to Know About MIPS

For ACO leaders, Promoting Interoperability reporting has become one of those requirements that sounds straightforward until you begin looking at how it applies across an organization. Different provider groups may use different electronic health record systems, individual clinicians may have different MIPS eligibility statuses, some providers may qualify for automatic reweighting, others may need hardship exceptions, and reporting may occur at different levels within the organization.

The complexity increased when CMS expanded the Medicare Shared Savings Program requirement for Promoting Interoperability. Beginning with the 2025 performance year, unless excluded, ACO participants, ACO providers and suppliers, and ACO professionals who are MIPS-eligible clinicians, Qualifying APM Participants, or Partial Qualifying APM Participants are generally expected under the Shared Savings Program requirement to report the MIPS Promoting Interoperability performance category and earn a performance category score. Importantly for ACO leadership, the Shared Savings Program requirement applies regardless of the risk track in which the ACO participates.

For 2026, however, there is an important additional layer. CMS is exercising enforcement discretion for the Shared Savings Program Promoting Interoperability requirement for both the 2025 and 2026 performance years. That means CMS has stated it will not take Shared Savings Program compliance action against an ACO for failing to meet those specific requirements during those years, and failure to meet the requirement will not affect the ACO's ability to earn or receive shared savings.

That does not mean Promoting Interoperability can simply be ignored.

The distinction between the Shared Savings Program requirement and MIPS reporting is critical. CMS has specifically stated that its enforcement discretion does not change MIPS Promoting Interoperability requirements for MIPS-eligible clinicians participating in an ACO.

That creates an important governance issue for ACOs. A clinician may be part of an ACO while still having an individual MIPS reporting obligation. A group may elect to report at the group level, which can affect the MIPS eligibility and payment adjustment implications for clinicians within that group. Qualifying APM Participants are generally excluded from MIPS payment adjustments, while Partial Qualifying APM Participants have different rules depending upon whether a MIPS election is made.

For ACO leadership, this means the question should not be, “Does our ACO have to report PI?” The more useful question is, “Which clinicians and provider groups within our organization have reporting obligations, exclusions, reweighting, or exception opportunities, and at what level should those requirements be managed?”

That requires a clinician-level and group-level understanding of the organization rather than a single ACO-wide assumption.

For the 2026 performance year, MIPS Promoting Interoperability generally requires the use of certified electronic health record technology and a minimum of 180 continuous days of data collection during the calendar year. Participants must satisfy applicable objectives, measures, and attestations, including requirements involving electronic prescribing, health information exchange, public health and clinical data exchange, security risk analysis, and other required Promoting Interoperability activities.

The actual submission period generally runs from January 2 through March 31 following the performance year, which means 2026 performance data will generally be submitted during the first quarter of 2027.

That timeline can create a false sense that reporting is a first-quarter activity. It is not. By the time the submission window opens, many of the decisions that determine whether successful reporting is possible have already been made.

ACO leaders need to know which providers are reporting, which EHR technology is being used, whether the appropriate certified technology is in place, whether required measures are being captured, whether required attestations and assessments are being completed, and whether exclusions or hardship circumstances exist. March is the submission deadline. It should not be the beginning of the reporting strategy.

CMS recognizes that some clinicians and groups may be unable to meet Promoting Interoperability requirements because of circumstances outside their control. For the 2026 performance year, the MIPS Promoting Interoperability Hardship Exception application is available through December 31, 2026, at 8 p.m. Eastern Time.

CMS currently identifies several circumstances that may support a hardship exception, including decertified EHR technology, insufficient internet connectivity, extreme and uncontrollable circumstances, and lack of control over the availability of certified electronic health record technology.

There are also circumstances in which CMS automatically reweights the Promoting Interoperability category based on special status. Depending on the applicable reporting structure, these may include clinicians who are hospital-based, ambulatory surgical center-based, non-patient-facing, or part of a qualifying small practice.

One distinction is particularly important for ACOs. An APM Entity, including an ACO, cannot submit a Promoting Interoperability Hardship Exception at the APM Entity level. Individual MIPS-eligible clinicians or groups within the APM Entity may submit a hardship application when eligible. APM Entities have a separate Extreme and Uncontrollable Circumstances exception process that applies across performance categories and has its own requirements.

That distinction makes early review essential. Waiting until the final weeks of the year to determine whether dozens or hundreds of clinicians need an exception creates unnecessary operational risk.

For many ACOs, Promoting Interoperability becomes difficult not because the requirements themselves are impossible to understand, but because the ACO is coordinating multiple independent organizations.

One participant may use Epic. Another may use athenahealth. Another may use eClinicalWorks or a smaller specialty-specific platform. Some groups may have sophisticated internal compliance teams, while others rely almost entirely on an outside EHR vendor. Provider rosters also change throughout the year as clinicians enter or leave practices.

The ACO therefore needs a repeatable process for determining:

• Which clinicians are included in each participating provider group and their applicable eligibility status
• Which groups intend to report individually, as a group, or through another available reporting structure
• Which certified EHR technology each group is using
• Whether required measures and attestations are being completed during the appropriate performance period
• Which clinicians or groups qualify for automatic reweighting
• Which organizations may need to submit a hardship exception before December 31
• Who is responsible for validating and submitting the final data before the March 31 reporting deadline

The goal is not to turn the ACO into the EHR administrator for every participating practice. The goal is to create enough centralized oversight that reporting gaps are identified while there is still time to correct them.

ACO leadership should also understand the implications of reporting at the group level. CMS has cautioned that submitting Quality, Promoting Interoperability, or Improvement Activities data at the group level can result in a MIPS score and payment adjustment for MIPS-eligible clinicians within that group, including clinicians who might not have been individually eligible because they were below the low volume threshold.

That means reporting structure is not simply an administrative choice. It can have consequences for individual clinicians.

Before an ACO or participating practice makes a group reporting decision, leadership should understand which clinicians will be included, what their individual eligibility status would otherwise be, whether any exclusions apply, and how the submission could affect MIPS participation and payment adjustments.

For organizations with multiple participant practices, this is another reason a single spreadsheet maintained at the end of the year is rarely sufficient. Eligibility, provider roster management, reporting level, EHR readiness, and exceptions should be monitored as part of the organization's broader compliance process.

At VSM, we view MIPS and Promoting Interoperability reporting as an operational process rather than an annual submission exercise. The objective is to establish visibility early enough that ACO leadership knows where potential gaps exist well before a CMS deadline becomes an emergency.

That begins with understanding the provider population. ACOs need accurate participant and clinician information, clear reporting responsibilities, visibility into eligibility and exclusion status, and regular communication with participating groups. From there, the organization can monitor readiness across EHR systems, identify groups that may require additional support, track hardship and exception considerations, and prepare for submission.

VSM helps create that structure across participating provider organizations, so ACO leadership is not discovering missing information during the final weeks of the reporting period. The value is not simply submitting data on time. It is reducing the operational uncertainty that comes from trying to coordinate different providers, systems, eligibility statuses, and reporting requirements across an entire ACO.

For the 2026 performance year, this is the time to validate the reporting strategy rather than wait for the submission window to open. ACOs should be reviewing clinician and participant rosters, confirming EHR and certified technology readiness, identifying reporting levels, tracking applicable exclusions, and determining whether any participating clinicians or groups may need hardship exceptions.

The key dates are straightforward: eligible hardship applications must be submitted by December 31, 2026, at 8 p.m. Eastern Time, and the standard 2026 MIPS data submission period will run through March 31, 2027. The work required to meet those dates, however, begins much earlier.

Promoting Interoperability is ultimately about more than checking a reporting box. It reflects CMS's continued movement toward a healthcare environment in which data can follow the patient, providers can exchange information across settings, and technology supports rather than fragments coordinated care.

For ACOs, the immediate responsibility is more practical. Know who needs to report, know who may qualify for an exception, know who owns each part of the process, and do not wait until the submission window to find out what is missing.

That level of preparation can turn Promoting Interoperability from an annual compliance scramble into a manageable part of ACO operations.