Response to Public Comments

Response to Comments
Quality Payment Program/Merit-Based Incentive Payment System (MIPS)
CMS- 10621, OMB 0938-1314
1. Burden for Third Party Reporting
a. Burden for Qualified Registry Self-Nomination
i. No comments.
b. Burden for QCDR Self-Nomination
i. Comment: A few commenters believe that the scope of proposals in the
proposed rule increases cost and burden to the point where some third-party
intermediaries may end their participation in MIPS. One commenter stated
that several provisions would additionally require it to alter business plans,
missions, and customer service priorities while another commenter cited
their belief that CMS is attempting to shift costs and burden of
administering the MIPS program onto specialty societies that create
measures and operate QCDRs.
ii. Response: We believe that our policies are intended to standardize and
raise the bar on the services and the quality of the third party intermediaries
we have in the MIPS program. Similar to years past, the standards and
requirements of QCDRs are higher when compared to that of qualified
registries, as we expect QCDRs to have extensive experience in quality
reporting, quality measure development, and clinical expertise to not just
facilitate reporting, but to also help address measurement gaps found within
the program. We believe that QCDRs and qualified registries should further
clinician goals of quality improvement by providing meaningful
information and services. While we estimate increases in the burden for
self-nomination, the burden per QCDR measure submitted for approval,
and the costs associated with developing measures and meeting
requirements for approval as a QCDR or registry, we believe that the
increased cost and burden are significantly outweighed by the positive
impact of the policies for MIPS eligible clinicians. We discuss the
financial impact of these proposals beyond reporting burden further in
section VII.E.10.f. of the RIA.
iii. Comment: One commenter believes that the “true costs” associated with a
QCDR application, whether using the simplified or full application, must
reflect more than the actual time to input the data required. The commenter
further cited costs such as creating and maintaining registries and QCDR
measures, recruitment of clinicians to develop quality improvement
initiatives, hiring staff to support and develop content and services
identified by these clinicians, and technology solutions necessary to
support the quality improvement services.
iv. Response: We recognize there are additional costs and administrative
burdens on respondents associated with self-nominating as a QCDR or

2.

3.
4.

5.
6.
7.

submitting a QCDR measure beyond the reporting burden estimated in the
Collection of Information section of this policy which only accounts for the
time required for record keeping, reporting, and third-party disclosures
associated with the policy. We discuss the financial impact of these
proposals beyond reporting burden further in section VII.E.10.f. of the
RIA. We understand that some respondents may require additional time
above the 0.5 hours we estimate for the simplified self-nomination process
and the 3 hours for the full self-nomination process, but given that we do
not include the costs to maintain registries or create measures and quality
improvement services in our burden estimate, we believe this estimate is a
reasonable average across all respondents based on our review of the
nomination process, the information required to complete the nomination
form, and the criteria required to self-nominate as a QCDR.
Burden for the Quality Performance Category
a. Burden for Quality Payment Program Identity Management Process
i. No comments.
b. Burden for Quality Data Submission by Clinicians: Medicare Part B ClaimsBased Collection Type
i. No comments.
c. Burden for Quality Data Submission by Individuals and Groups: MIPS CQM and
QCDR Collection Types
i. No comments.
d. Burden for Quality Data Submission by Clinicians and Groups: eCQM Collection
Type
i. No comments.
e. Burden for Quality Data Submission by CMS Web Interface
i. No comments.
f. Burden for Group Registration for CMS Web Interface
i. No comments.
Burden Estimate for the Nomination of Quality Measures
a. No comments.
Burden Estimate for the Promoting Interoperability Performance Category
a. Burden for Reweighting Applications for Promoting Interoperability and Other
Performance Categories
i. No comments.
b. Burden for Submitting Promoting Interoperability Data
i. No Comments.
Burden Estimate for the Nomination of Promoting Interoperability Measures
a. No comments.
Burden Estimate for the Submission of Improvement Activities Data
a. No comments.
Burden Estimate for the Nomination of Improvement Activities
a. No comments.

8. Burden Estimate for the Cost Performance Category
a. No comments.
9. Burden Estimate for Partial QP Elections
a. No comments.
10. Burden Estimate for Other-Payer Advanced APM Determinations
a. Payer-Initiated Process
i. No comments.
b. Eligible Clinician-Initiated Process
i. No comments.
c. Submission of Data for QP Determinations under the All-Payer Combination
Option
i. No comments.
11. Burden Estimate for Voluntary Participants to Elect Opt-Out of Performance Data
Display on Physician Compare
a. No comments.