Most conversations about MIPS start with the measures. Depression screening. Colorectal screening. A1c control. Every practice knows the list.
The harder question is much more ordinary: which of your patients still has something open, who is supposed to handle it, and does the ACO know when it’s done?
That was the problem we set out to solve. Not “close the metrics,” but make it possible for a busy office to know what was open and do something about it.
The clearest result so far is in the ACO’s own data. At one practice, the share of Medicare ACO patients with an Annual Wellness Visit reached 74.5% by the end of 2025, up from 23% at the end of 2024. In the years before that, it had never passed 33%.
The information was all there, just not in one place
The ACO’s portal knew which patients had been discharged from a hospital, who was due for an Annual Wellness Visit, and which chronic conditions hadn’t been coded yet this year. The EHR knew who had an appointment and what had been billed. The fax pile knew about the colonoscopy done across town.
None of those systems talked to each other. So the portal could list a patient as “not scheduled” when the front desk had already booked the visit in the EHR. Nobody was going to re-key every appointment into a second system. The practice looked behind even when it wasn’t.
So we built a data lake: one place where the practice’s appointments, claims, and quality data live together. Then we connected the ACO’s portal to it through its API. Hospital alerts, open opportunities, and patient charts now arrive automatically, and each one is matched to the right patient in the EHR.
Now we can ask the question that matters for each patient: what does the ACO still consider open, and what has the practice already done?
If the practice already billed something the ACO still lists, the ACO is behind, and the provider doesn’t need to be asked about it again. If it really is open, it becomes work for someone.
The gap is easy to see. In late October 2026, the portal listed 138 of one practice’s patients as “dropped,” meaning not seen. Billing showed that 61 of them, 44%, had already had a visit that year. Some of that is simply claims taking weeks to reach the portal, but without comparing the two, your staff would be chasing patients who already came in.
There is too much to do, so we made it smaller
Knowing what’s open isn’t enough. A report listing several hundred open opportunities doesn’t get anything done. It gets closed and forgotten, because nobody can face it between phone calls.
Large goals get hit when they are broken into pieces small enough to finish. So each part of the practice gets its own list, with only the work that person can do.
The front desk creates the visits. Patients discharged from a hospital get a follow-up inside 14 days. Patients due for a wellness visit get called. Patients who need a refill and haven’t been seen get scheduled. Each day is a short list of specific people to contact, not a dashboard to interpret.
Medical assistants and providers see what’s open before the visit. When the patient is in the room, a prep sheet shows what can be closed today: the PHQ-9 that’s due, the colorectal screening that isn’t documented, the diagnosis that hasn’t been addressed this year.
Billing makes sure the work reaches the claim. A measure done in the room but missing from the claim is, as far as the payer is concerned, a measure not done.
No one has to think about MIPS as a whole. They finish their list, and the measures close as a result.
The numbers have kept moving. By mid-2026, Annual Wellness Visits for those Medicare patients stood at 28%, compared with 13% at the same point in 2025. Follow-up after a hospital discharge improved too: transitional care visits went from about 15% of discharges in the first half of 2025 to about 41% in the first half of 2026.
Then we tell the ACO
This is the step that’s easy to overlook. Closing a gap in your own office doesn’t mean the ACO can see it.
Because we’re connected to the portal, the visits your front desk books in the EHR can be reported back to it, so a patient with an appointment stops showing as unscheduled. Every update is checked against the portal and the EHR right before it goes out. If the appointment moved or the opportunity is no longer open, nothing is sent. A named person approves what goes.
That’s what better communication with the ACO means in practice: both sides looking at the same picture, without your staff doing the data entry twice.
What it’s for
The ACO bonus and the chronic disease credit are the visible results. But they follow from something simpler: a practice where everyone knows what’s next, and a patient who gets the screening they were due for.
Next in this series: the fax that closes a measure, and getting your providers out of the clicks.