Meet the Experts: Renee Freyer, MIPS Consulting Services

With nearly 20 years in healthcare, Renee Freyer has seen the challenges of the Merit-based Incentive Payment System (MIPS) from multiple angles. Her experience in clinical care and operations shapes the insight that she shares through Verana Health MIPS Advisory Services. 

In this conversation, Renee describes how she encourages providers to view MIPS not simply as a compliance requirement but an integral part of delivering quality care. She discusses common challenges, including keeping up with regulatory changes and selecting the right quality measures to report, as well as misconceptions to avoid (MIPS reporting isn’t just for Medicare patients!) and strategies for maximizing MIPS scores. 

Read on to learn more and see how she can help simplify MIPS for your practice.

What led you to specialize in MIPS consulting?

I’ve worked in healthcare for nearly 20 years across a variety of roles. I began my career in mental health, supporting Medicaid patients with complex psychiatric diagnoses. Over time, I developed a passion for supporting healthcare delivery from the operational side, which led me to work with an operating room electronic health record (EHR) and diagnostic monitoring company, providing support to perfusionists and anesthesiologists. 

Since 2017, I’ve specialized in MIPS, and in 2020, I transitioned into a consulting role, working primarily with ophthalmology practices, as well as dermatology, orthopedics, and ear, nose and throat (ENT). 

This journey has given me a deep understanding of both clinical workflows and regulatory requirements, which helps me bridge the gap between care delivery and MIPS compliance.

Briefly explain what MIPS is and why it’s important for healthcare providers?

MIPS, short for the Merit-based Incentive Payment System, is a Medicare program that adjusts how much providers get paid based on how well they perform. It looks at things like the quality of care delivered, efforts to improve care, and how technology is used in the practice. The better the performance, the better the potential payment adjustment. 

MIPS matters because it aims to improve patient care while giving providers the opportunity to earn incentives, or at the very least, avoid penalties, for meeting specific standards.

How has your experience strengthened your understanding of the challenges providers face with MIPS reporting and compliance?

From my time providing direct patient care and shadowing clinicians over the years, I’ve seen just how frustrating MIPS reporting can feel. Many providers describe it as just “clicking buttons,” and it’s easy to understand why. It can feel like a distraction from what really matters: taking care of patients. That experience helped me understand how important it is to connect MIPS to the bigger picture.

A good example is Measure 130 in the Quality category: Medication Documentation Attestation. On the surface, it can seem like just another box to check. But it’s really about patient safety. Having an accurate and up-to-date medication list helps avoid drug interactions. It’s not just about MIPS compliance. It’s about good clinical care.

Framing MIPS this way helps it feel less like a burden and more like something that supports what providers are already focused on: delivering safe, high-quality care.

What are common challenges healthcare providers face with MIPS reporting and compliance?

A big challenge is just keeping up with how often MIPS changes. Each year, there are updates to the rules, scoring, and measure requirements, which can make it tough to know exactly what to focus on. 

Choosing the right Quality measures is another common issue. Practices want to report on what makes sense clinically, but also what gives them the best chance to score well. 

And even when performance is strong, data doesn’t always flow correctly from the EHR, so identifying any mapping issues early on is key to getting full credit for the work being done.

How do you see AI and technology playing a role in improving MIPS performance?

EHRs have come a long way in helping practices by alerting them when MIPS documentation is completed for patients. But the way these alerts work can vary. Some systems are better than others at making those notifications clear and helpful. And these alerts don’t always cover every measure, especially if a practice is using customized ways of reporting or using a qualified clinical data registry (QCDR) like Verana Health, which has many additional Quality measures available compared to an EHR.

At Verana Health, we’re advancing AI-based tools and technology to make MIPS compliance even more efficient. These efforts help us quickly identify trends and errors in Quality category documentation, making it easier to catch issues and improve performance.

In your experience, what’s the biggest misconception providers have about MIPS?

There are two big misconceptions I often see. The first is if a practice misunderstands a MIPS measure or rule, the Centers for Medicare & Medicaid Services (CMS) will be lenient during an audit. Unfortunately, that’s not the case. Practices are ultimately responsible for understanding and keeping up with the evolving MIPS requirements. 

That’s where our coaching and advisory services can be a real benefit. We help simplify the complex regulatory landscape, so you can stay compliant without the guesswork. And because the rules change every year, we make sure you’re informed on what’s new and what it means for your practice.

The second misconception is that many clinicians believe they only need to complete documentation for Medicare patients, since MIPS ties performance to Medicare reimbursement. However, MIPS requires reporting on all measure-eligible patients, regardless of payer, not just those with Medicare.

What strategies do you use to help clients maximize their MIPS scores?

When I’m helping clients boost their MIPS scores, I always start by making sure they’re tracking the right measures – ones that actually make sense for their practice. Then I dig into the details to spot any documentation gaps or mapping issues that might bring their score down. I keep an eye on their performance throughout the year so we can fix problems early instead of scrambling at the end.

How do you stay current on the latest changes and updates to MIPS regulations?

I stay current by reviewing email alerts from CMS and other regulatory sources, along with the preliminary and final rules released each year and the associated volume of supporting documentation. Since MIPS rules change annually, and sometimes more frequently, it’s essential to keep a close eye on updates. If anything is unclear, I’ll reach out directly to CMS or the Quality Payment Program (QPP) support team for clarification to ensure everything is interpreted accurately.

What are you most excited about in joining the Verana Health team?

As the exclusive partner of the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) we are able to work first hand with the processing team to ensure accurate data and optimal outcomes. It’s exciting to be part of expanding our MIPS advisory services, working at the company that houses and processes the MIPS data. 

What advice would you give to healthcare providers looking to improve their MIPS performance?

Make sure your documentation lines up with the measures you’re reporting on and that it’s done consistently. Pick measures that fit your day-to-day workflow and that you can realistically do well on. Don’t wait until the end of the year to look at how you’re doing; checking in regularly can help you catch issues early. And don’t hesitate to ask for support. Getting help can save you time and stress.

What do you like to do for fun outside of work?

Improv! I’m on a Game Night team – think “Who’s Line Is It Anyway?” I enjoy the creativity, quick-thinking skills and friendships I’ve gained from performing and practicing improv. I also enjoy spending time with my husband going to the mountains/hiking and playing with our goldendoodle, Charlee. We refer to her personality like a cat-dog. She lets you know when she wants to be left alone and only wants affection when requested.

Anything else you’d like to share? Contact us to learn how we can help simplify MIPS for your practice!