Supporting Statement – Part A
Quality Payment Program/Merit-Based Incentive Payment System (MIPS)
CMS-10621, OMB 0938-1314
The Merit-based Incentive Payment System (MIPS) is a program for certain eligible clinicians that makes Medicare payment adjustments based on performance on quality, cost and other measures and activities. MIPS and Advanced Alternative Payment Models (AAPMs) are the two paths for clinicians available through the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As prescribed by MACRA, MIPS focuses on the following: quality – both a set of evidence-based, specialty-specific standards; practice-based improvement activities; cost; and use of Certified Electronic Health Record Technology (CEHRT) to support interoperability and advanced quality objectives in a single, cohesive program that avoids redundancies.
Under the AAPM path, eligible clinicians may become Qualifying APM Participants (QPs) and are excluded from MIPS. Partial Qualifying APM Participants (Partial QPs) may opt to report and be scored under MIPS. Where Partial QP status is earned at the APM Entity level the burden of Partial QP election would be incurred by a representative of the participating APM Entity. For Advanced APMs where Partial QP status is earned at the eligible clinician level, the burden of Partial QP election would be incurred by the eligible clinician. APM Entities and eligible clinicians must also submit all of the required information about the Other Payer Advanced APMs in which they participate, including those for which there is a pending request for an Other Payer Advanced APM determination, as well as the payment amount and patient count information sufficient for us to make QP determinations by December 1 of the calendar year that is 2 years to prior to the payment year, which we refer to as the QP Determination Submission Deadline (82 FR 53886).
The implementation of MIPS requires the collection of quality, Promoting Interoperability, and improvement activities performance category data.1 For the quality performance category, MIPS eligible clinicians and groups will have the option to submit data using various submission types, including Medicare claims, direct, log in and upload, CMS Web Interface and CMS-approved survey vendors.2 Virtual groups are subject to the same requirements as groups, therefore, we will refer only to groups as an inclusive term for both unless otherwise noted. For the improvement activities and Promoting Interoperability, clinicians and groups can submit data through direct, log in and upload, or log in and attest submission types. As finalized in the CY 2021 PFS final rule (85 FR 84860), for clinicians in APM Entities, the APM Performance Pathway will be available for both ACOs and non ACOs to submit quality data. Due to data limitations and our inability to determine who would use the APM Performance Pathway versus the traditional MIPS submission mechanism for the CY 2022 MIPS performance period/2024 MIPS payment year, we assume ACO APM Entities will submit data through the APM Performance Pathway, using the CMS Web Interface option, and non-ACO APM Entities would participate through traditional MIPS, thereby submitting as an individual or group rather than as an entity. We are proposing in the CY 2022 PFS proposed rule to extend the CMS Web Interface measures as a quality performance category collection type/submission type for the CY 2022 MIPS performance period/2024 MIPS payment year. We are also proposing to sunset the CMS Web interface measures as a quality performance category collection type/submission type starting with the CY 2023 MIPS performance period/2025 MIPS payment year. If this proposal is finalized, beginning with January 1, 2023 (which is the start of the CY 2023 MIPS performance period), groups of 25 or more clinicians that previously submitted quality performance data via the CMS Web Interface will be required to use an alternate collection type, which will have to be either the MIPS Clinical Quality Measures (CQM) and Qualified Clinical Data Registry (QCDR) or Electronic Clinical Quality Measures (eCQM) collection type.
In the CY 2022 PFS proposed rule (86 FR 39356 through 39357), we propose to implement voluntary MIPS Value Pathways (MVP) reporting for eligible clinicians beginning with January 1 of the CY 2023 MIPS performance period/2025 MIPS payment year. Beginning with the CY 2023 MIPS performance period/2025 MIPS payment year, we are also proposing voluntary subgroup reporting within MIPS limited to eligible clinicians reporting through the MVPs or the APP (86 FR 39357 through 39358).
For the Promoting Interoperability performance category, in the CY 2022 PFS proposed rule, we propose that, beginning with the CY 2022 MIPS performance period/2024 MIPS payment year, eligible clinicians must attest to conducting an annual assessment of the High Priority Guides of the SAFER Guides beginning January 1 of CY 2022 (86 FR 39415). We also propose to automatically reweight the Promoting Interoperability for small practices who had to apply for reweighting of this performance category in previous years (86 FR 39448 through 39449).
For the improvement activities performance category, we are proposing two new criteria for nomination of improvement activities, that beginning with the CY 2022 Annual Call for MIPS improvement activities: (1) should not duplicate other improvement activities in the Inventory; and (2) should drive improvements that go beyond purely common clinical practices. We are also proposing to increase the number of required criteria for stakeholders to submit an activity proposal from a minimum of 1 to all 8 criteria, which includes the above two new proposed criteria (86 FR 39406 through 39408).
The implementation of MIPS requires the collection of additional data beyond performance category data submission. Qualified registries and QCDRs must complete a self-nomination form submitted electronically using a web-based tool to CMS before they can submit data on behalf of eligible clinicians. Virtual group representatives must make an election on behalf of the members of their virtual group, regarding the formation of the virtual group prior to the start of the MIPS performance period. In order to use either the log in and upload or log in and attest submission types or to access feedback reports, clinicians, groups, virtual groups, or third parties who do not already have CMS Enterprise Portal user accounts must register for one. Clinicians, groups, and other relevant stakeholders may nominate new improvement activities, Promoting Interoperability measures, quality measures, and MIPS Value Pathways (MVPs) using nomination forms provided on the Quality Payment Program website at qpp.cms.gov, and in the case of quality measures must also submit a completed Peer Review Journal Article form also provided on the Quality Payment Program website.
We are requesting approval of 26 information collections associated with the CY 2022 PFS proposed rule as a proposed revision to our currently approved (or active) information requests submitted under this package’s control number (OMB 0938-1314, CMS-10621). CMS has already received approval for collection of information associated with the CAHPS for MIPS survey under OMB control number 0938-1222 (CMS-10450). CMS has already received approval for collection of information associated with the virtual group election process under OMB control number 0938-1343 (CMS-10652).
The proposed changes in this CY 2022 collection of information request are associated with our July 23, 2021 (86 FR 39104) proposed rule (CMS-1734-F, RIN 0938-AU42).
Where updated data and assumptions was available for the CY 2022 PFS proposed rule, we have made adjustments to applicable ICRs. Ten MIPS ICRs [(1) QCDR self-nomination applications, (2) Qualified Registry self-nomination applications, (3) quality performance category data submission by Medicare Part B Claims collection type, (4) quality performance category data submission by QCDR and MIPS CQM collection type, (5) quality performance category data submission by eCQM collection type, (6) quality performance category data submission by CMS Web Interface collection type, (7) group registration for the CMS Web Interface, (8) nomination of improvement activities, (9) reweighting applications for Promoting Interoperability and other performance categories, and (10) Promoting Interoperability performance category data submission] reflect changes in burden due to proposed policies in the CY 2022 PFS proposed rule. In aggregate, we estimate that the proposed policies will result in a net increase in burden of 3,620 hours and $340,778 for the CY 2022 MIPS performance period/2024 MIPS payment year. . In total, we estimate a decrease in burden of 39,763 hours and $3,827,868for the CY 2022 MIPS performance period/2024 MIPS payment year due to updated data and assumptions as well as proposed policies.. We are setting forth our proposed burden for the CY 2023 MIPS performance period/2025 MIPS payment year as new burden. The total proposed burden for the CY 2023 MIPS performance period/2025 MIPS payment year is 1,390,404 hours and $140,284,742.The proposed policy to require approved QCDRs and qualified registries to submit participation plans if they did not submit any MIPS data for either of the 2 years preceding the applicable self-nomination period will increase the annual burden hours for both QCDRs and qualified registries by 3 hours per participation plan. The proposed policy to sunset the CMS Web Interface measures as a collection type/submission type starting with the CY 2023 MIPS performance period/2025 MIPS payment year will increase the number of respondents for the MIPS CQM QCDR, and eCQM collection types for the quality performance category by 50 and 64 respondents, respectively, as we assume respondents who previously submitted via the CMS Web Interface collection type would alternatively utilize one of these collection types to submit quality data. The proposed policy for annual assessment of SAFER Guides requirement beginning with the CY 2023 MIPS performance period/2025 MIPS payment year will result in an increase of 0.02 hours per respondent. The proposed policy to automatically reweight the Promoting Interoperability performance category for small practices who had to previously apply for reweighting would result in a decrease of 13,894 respondents. The proposed policy to require all 8 criteria, including two new criteria, to be met for submitting an improvement activity for consideration will increase the time by 1.4 hours per improvement activity. The remaining changes to our currently approved burden estimates are adjustments due to the use of updated data sources.
We are also proposing to add three new ICRs: MVP registration, MVP quality submissions, and Subgroup registration. The MVP registration reflects the burden associated with the proposed registration process for clinicians reporting MVPs beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. Subgroup registration reflects the burden associated with the proposed registration process for subgroups reporting the MVPs. The MVP quality submission reflects the decrease in burden associated with the proposed MVP Inventory available for MIPS eligible clinicians.
The proposed processes for reporting quality performance category data will be generally the same for the CY 2022 MIPS performance period/2024 MIPS payment year as they were in the CY 2021 MIPS performance period/2023 MIPS payment year. Under MIPS, the quality performance category performance requirements for clinicians participating in traditional MIPS are as follows: the MIPS eligible clinician or group will report at least 6 measures including at least 1 outcome measure if available; and if an applicable outcome measure is not available, then the MIPS eligible clinician or group will report a high priority measure (appropriate use, patient safety, efficiency, patient experience, care coordination, or opioid-related measures) in lieu of an outcome measure. If fewer than 6 measures apply to the individual MIPS eligible clinician or group, then the MIPS eligible clinician or group will be required to report on each measure that is applicable.
For the CY 2023 MIPS performance period/2025 MIPS payment year, we propose in the CY 2022 PFS proposed rule that for clinicians participating in MIPS through MVPs, an individual, group, subgroup, or an APM Entity must select and report 4 quality measures, including 1 outcome measure (or, if an outcome measure is not available, 1 high priority measure, included in the MVP (86 FR 39370 through 39371). In the CY 2022 PFS proposed rule (86 FR 39357 through 39358), we also propose the introduction of voluntary subgroup reporting beginning with the CY 2023 MIPS performance period/2025 MIPS payment year, which allows a portion of the clinicians in a TIN to voluntarily report on the measures and activities in an MVP and receive their own performance feedback.
As established in the CY 2018 Quality Payment Program final rule, we allow MIPS eligible clinicians to apply for a redistribution of the weights for the quality, cost, and improvement activities performance categories due to hardship exceptions such as a natural disaster (82 FR 53783 through 53785). We rely on section 1848(q)(5)(F) of the Social Security Act, as amended by section 4002(b)(1)(B) of the 21st Century Cures Act, as our authority for these exemptions.
Section 1848(q)(2)(A) of the Act includes the meaningful use of CEHRT as a performance category under the MIPS.
For the CY 2022 MIPS performance period, we are proposing to add a new SAFER Guides measure to the Protect Patient Health Information objective, beginning with the CY 2022 MIPS performance period/2024 MIPS payment year. For this measure, we are proposing that a MIPS eligible clinician or group must attest to having conducted an annual self-assessment using the High Priority Practices Guide (available at https://www.healthit.gov/topic/safety/safer-guides), at any point during the calendar year in which the performance period occurs, with one “yes/no” attestation statement accounting for the complete self-assessment using the guide. We propose that this measure would be required, but it would not be scored, and that reporting “yes” or “no” would not affect the total number of points earned for the Promoting Interoperability performance category.
As established in the CY 2017 and CY 2018 Quality Payment Program final rules, MIPS eligible clinicians who meet the criteria for a significant hardship or other type of exception may submit an application requesting a zero percent weighting for the Promoting Interoperability, quality, cost, and/or improvement activities performance categories under specific circumstances (81 FR 77240 through 77243, 82 FR 53680 through 53686, and 82 FR 53783 through 53785). In the CY 2022 PFS proposed rule (86 FR 39448 through 39449), we are proposing to no longer require an application for clinicians and small practices seeking to qualify for the small practice hardship exception and reweighting. We are proposing instead to assign a weight of zero percent to the Promoting Interoperability performance category and redistribute its weight to another performance category or categories in the event no data is submitted for any of the measures for the Promoting Interoperability performance category by or on behalf of a MIPS eligible clinician in a small practice. In the CY 2022 PFS proposed rule (86 FR 39426), we propose to apply the automatic reweighting of the Promoting Interoperability performance category to clinical social workers. We rely on section 1848(q)(5)(F) and section 1848(o)(2)(D) of the Act, as amended by section 4002(b)(1)(B) of the 21st Century Cures Act, as our authority for these exemptions.
Under MIPS, clinical practice improvement activities are referred to as improvement activities. We are encouraging, but not requiring, a minimum number of improvement activities, conducted at the group or the individual level. MIPS eligible clinicians and groups can submit data through direct, log in and upload, or log in and attest submission types. We are not proposing any changes to the scoring methodology for the CY 2022 MIPS performance period/2024 MIPS payment year.
Under MIPS, we refer to the resource use performance category as “cost.” The cost performance category measures are derived from the Medicare Parts A and B claims submission process. Cost performance category measures do not result in any submission burden because individual MIPS eligible clinicians are not asked to provide any documentation beyond the claims submission process.
Under MIPS, there are information collections beyond performance category data submission. Other data submitted on behalf of MIPS eligible clinicians include virtual group elections, CAHPS for MIPS registrations, and reweighting applications.
The adjustments to the policies finalized in Quality Payment Program and PFS final rules from CY 2017 through CY 2021 and the proposed policies in the CY 2022 PFS proposed rule create some additional data collection requirements not listed in Table 2. The additional data collections consist of:
Self-nomination and other requirements for new and returning QCDRs
Self-nomination and other requirements for new and returning qualified registries
Open Authorization Credentialing and Token Request Process
QPP Identity Management Application Process
Reweighting Applications for Promoting Interoperability and Other Performance Categories
Call for quality measures
Nomination of new improvement activities
Call for Promoting Interoperability measures
Nomination of MVPs
Opt out of performance data display on Physician Compare for voluntary reporters under MIPS
This information request includes four information collections related to Advanced APMs. These four additional data collections are as follows:
Partial Qualifying APM Participant (Partial QP) election
Other Payer Advanced APM determinations: Payer Initiated Process
Other Payer Advanced APM determinations: Eligible Clinician Initiated Process
Submission of Data for All-Payer QP Determinations
APM Entities may face a data submission burden under MIPS related to Partial QP elections. Partial QPs will have the option to elect whether to report under MIPS, which determines whether they will be subject to MIPS scoring and payment adjustments. For the 2022 QP Performance Period, we define Partial QPs to be eligible clinicians in Advanced APMs who collectively have at least 40 percent, but less than 75 percent, of their payments for Part B covered professional services through an APM Entity or furnish Part B covered professional services to at least 25 percent, but less than 50 percent, of their Medicare beneficiaries through an APM Entity. If an Advanced APM Entity is notified that they attain Partial QP status, a representative from the APM Entity will log into the MIPS portal to indicate whether all eligible clinicians participating in the APM Entity meeting the Partial QP threshold wish to participate in MIPS. If the Partial QP elects to be scored under MIPS, they would be subject to all MIPS requirements and would receive a MIPS payment adjustment. If an eligible clinician does not attain either QP or Partial QP status, and does not meet any another exemption category, the eligible clinician would be subject to MIPS, would report to MIPS, and would receive the corresponding MIPS payment adjustment.
As detailed in CMS 5522-FC, the All-Payer Combination Option is an available pathway to QP or Partial QP status for eligible clinicians participating sufficiently in Advanced APMs and Other Payer Advanced APMs. This Option allows for eligible clinicians to achieve QP status through their participation in both Advanced APMs and Other Payer Advanced APMs. To provide eligible clinicians with advanced notice prior to the start of a given performance period/payment year, and to allow other payers to be involved prospectively in the process, we provided in the CY 2018 Quality Payment Program final rule a payer-initiated process for identifying payment arrangements that qualify as Other Payer Advanced APMs (82 FR 53844). The Payer-Initiated Process for Other Payer Advanced APM determinations began in CY 2018 for Medicaid, Medicare Health Plans, and payers participating in CMS Multi-Payer Models. Also, in the CY 2018 Quality Payment Program final rule we established that remaining other payers, including commercial and other private payers, may also request that we determine whether other payer arrangements are Other Payer Advanced APMs (82 FR 53867). In the CY 2019 PFS final rule, we eliminated the Payer Initiated Process that is specifically for CMS Multi-Payer Models.
As finalized in the CY 2018 Quality Payment Program, APM Entities and eligible clinicians participating in other payer arrangements have an opportunity to request that we determine for the year whether those other payer arrangements are Other Payer Advanced APMs (82 FR 53857 through 53858). As finalized in the CY 2018 Quality Payment Program final rule, APM Entities and eligible clinicians may request determinations for any Medicaid payment arrangements in which they are participating at an earlier point, prior to the start of a given QP performance period (82 FR 53858) via the eligible clinician-initiated determination process for Other Payer Advanced APMs.
We finalized in the CY 2017 Quality Payment Program final rule that APM Entities or individual eligible clinicians must submit by a date and in a manner determined by us: (1) payment arrangement information necessary to assess whether each other payer arrangement is an Other Payer Advanced APM, including information on financial risk arrangements, use of CEHRT, and payment tied to quality measures; (2) for each payment arrangement, the amounts of payments for services furnished through the arrangement, the total payments from the payer, the numbers of patients furnished any service through the arrangement (that is, patients for whom the eligible clinician is at risk if actual expenditures exceed expected expenditures); and (3) the total number of patients furnished any service through the arrangement (81 FR 77480). If we do not receive sufficient information to complete our evaluation of another payer arrangement and to make QP determinations for an eligible clinician using the All-Payer Combination Option, we cannot assess the eligible clinicians under the All-Payer Combination Option.
As explained in the CY 2018 Quality Payment Program final rule, in order for us to make QP determinations under the All-Payer Combination Option using either the payment amount or patient count method, we need to receive all of the payment amount and patient count information: (1) attributable to the eligible clinician or APM Entity through every Other Payer Advanced APM; and (2) for all other payments or patients, except from excluded payers, made or attributed to the eligible clinician during the QP performance period (82 FR 53885). In the same rule, we finalized that APM Entities or eligible clinicians must submit all of the required information about the Other Payer Advanced APMs in which they participate, including those for which there is a pending request for an Other Payer Advanced APM determination, as well as the payment amount and patient count information sufficient by the QP Determination Submission Deadline (82 FR 53886).
In the CY 2019 PFS final rule, we added a third alternative to allow QP determinations at the TIN level in instances where all clinicians who have reassigned billing rights to the TIN participate in a single APM Entity (83 FR 59936). This option is available to all TINs participating in Full TIN APMs, such as the Medicare Shared Savings Program. To make QP determinations under the All-Payer Combination Option at the TIN level using either the payment amount or patient count method, we will need to receive, by December 1 of the calendar year that is 2 years to prior to the payment year, all of the payment amount and patient count information: (1) attributable to the eligible clinician, TIN, or APM Entity through every Other Payer Advanced APM; and (2) for all other payments or patients, except from excluded payers, made or attributed to the eligible clinician(s) during the QP performance period for the periods January 1 through March 31, January 1 through June 30, and January 1 through August 31 sufficient for us to make QP determinations.
Our authority for collecting this information is provided by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, April 16, 2015) which further amended section 1848 and 1833 of the Act, respectively.
Section 1848(q) of the Act requires the establishment of the MIPS beginning with payments for items and services furnished on or after January 1, 2019, under which the Secretary is required to: (1) develop a methodology for assessing the total performance of each MIPS eligible clinician according to performance standards for a performance period; (2) using the methodology, provide a final score for each MIPS eligible clinician for each performance period; and (3) use the final score of the MIPS eligible clinician for a performance period to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor for exceptional performance) to the MIPS eligible clinician for a performance period. Under section 1848(q)(2)(A) of the Act, a MIPS eligible clinician’s final score is determined using four performance categories: (1) quality; (2) cost; (3) improvement activities, and (4) Promoting Interoperability. Section 1833(z) of the Act establishes incentive payments for clinicians who are qualifying participants in advanced APMs.
CMS will use data reported or submitted by MIPS eligible clinicians as individual clinicians (both required and voluntary) or as part of groups, subgroups, virtual groups, or APM entities. CMS will use this data to assess MIPS eligible clinician performance in the MIPS performance categories, calculate the final score (including whether or not requirements for certain performance categories can be waived), and calculate positive and negative payment adjustments based on the final score, and to provide feedback to the clinicians. Information provided by third party intermediaries may also be used for administrative purposes such as determining third party intermediaries and QCDR measures appropriate for the MIPS program. Information provided by clinicians, professional societies, and other respondents will be used to consider quality and Promoting Interoperability measures, improvement activities, and MVPs for inclusion in the MIPS program. Information provided by payers, APM Entities, and eligible clinicians will be used to determine which additional payment arrangements qualify as Other Payer Advanced APM models. In order to administer the Quality Payment Program, the data will be used by agency contractors and consultants and may be used by other federal and state agencies.
We also use this information to provide performance feedback to MIPS eligible clinicians and eligible entities. Clinicians and beneficiaries can view performance category data and final scores for a MIPS performance period/MIPS payment year on compare tools hosted by the U.S. Department of Health and Human Services. The data also may be used by CMS authorized entities participating in health care transparency projects. The data is used to produce the annual Quality Payment Program Experience Report which provides a comprehensive representation of the overall experience of MIPS eligible clinicians and subgroups of MIPS eligible clinicians.
Relevant data will be provided to federal and state agencies, Quality Improvement Networks, the Small, Underserved, and Rural Support (SURS) technical assistance contractors, and parties assisting consumers, for use in administering or conducting federally funded health benefit programs, payment and claims processes, quality improvement outreach and reviews, and transparency projects. In addition, this data may be used by the Department of Justice, a court, or adjudicatory body, another federal agency investigating fraud, waste, and abuse, appropriate agencies in the case of a system breach, or the U.S. Department of Homeland Security in the event of a cybersecurity incident. Lastly, CMS has made available a Public Use File presenting a comprehensive data set on performance of all clinicians across all categories, measures, and activities for MIPS which will be updated annually.
All the information collection described in this form is to be conducted electronically.
The information to be collected is not duplicative of similar information collected by the CMS external to MIPS.
With respect to participating in MIPS for MIPS APM participants, CMS has set forth requirements that encourage limiting duplication of effort, but in the interest of providing flexibility in reporting, we cannot ensure that duplication does not occur. In addition, as discussed in later sections, many APM Entities will not need to submit improvement activities because they will be reporting through the APM Performance Pathway (APP). For CY 2022 MIPS performance period/2024 MIPS payment year, we assume that all MIPS APM models will qualify for the maximum improvement activities performance category score and the APM Entities reporting the APP will not need to submit any additional improvement activities. We assume ACO APM Entities will submit data through the APM Performance Pathway and non-ACO APM Entities would participate through traditional MIPS, thereby submitting as an individual or group rather than as an APM entity.
Because the vast majority of Medicare clinicians that receive Medicare payment under the PFS (approximately 95 percent) are small entities within the definition in the Regulatory Flexibility Act (RFA), HHS’s normal practice is to assume that all affected clinicians are "small" under the RFA. In this case, most Medicare and Medicaid eligible clinicians are either non-profit entities or meet the Small Business Administration’s size standard for small business. The CY 2022 PFS proposed rule’s Regulatory Impact Analysis estimates that approximately 809,625 MIPS eligible clinicians will be subject to MIPS performance requirements.3 The low-volume threshold is designed to limit burden to eligible clinicians who do not have a substantive business relationship with Medicare. We estimate that approximately 100,501 clinicians in eligible specialties will be excluded from MIPS data submission requirements because they do not have sufficient charges, services or beneficiaries under the PFS and thus do not meet opt-in volume criteria as either a group or individual. Additionally, we exclude 411,872 clinicians who are not MIPS eligible as individual clinicians and did not participate as a group, but could elect to participate in MIPS through opting in or participating as a group. Further, we exclude an additional 303,873 clinicians who are either QPs, newly enrolled Medicare professionals (to reduce data submission burden to those professionals), or practice non-eligible specialties. Clinicians who do not meet the low-volume threshold, or who are newly enrolled Medicare clinicians may opt to submit MIPS data. Medicare professionals voluntarily participating in MIPS would receive feedback on their performance but would not be subject to payment adjustments.
In the Regulatory Impact Analysis section of the CY 2022 PFS proposed rule (86 FR 39549), we explain that we assume 809,625 MIPS eligible clinicians will submit data as individual clinicians, or as part of groups or as APM entities. Included in this number, we estimate 3,259 clinicians who exceeded at least one but not all low-volume threshold, elected to opt-in and submitted data in the CY 2019 MIPS performance period/2021 MIPS payment year will elect to opt-in to MIPS in the CY 2022 MIPS performance period/2024 MIPS payment year.
Additionally, we estimate that for the CY 2022 QP Performance Period between 225,000 and 290,000 eligible clinicians will become QPs, therefore be excluded from MIPS, and qualify for the lump sum APM incentive payment in 2024 MIPS Payment Year based on 5 percent of their Part B paid amounts for covered professional services in the preceding year.
Data on the quality, Promoting Interoperability, and improvement activities performance categories are collected from individual MIPS eligible clinicians or groups annually. If this information was collected less frequently, we will have no mechanism to: (1) determine whether a MIPS eligible clinician or group meets the performance criteria for a payment adjustment under MIPS; (2) calculate for payment adjustments to MIPS eligible clinicians or groups; and (3) publicly post clinician performance information on the compare tools hosted by the U.S. Department of Health and Human Services. We require additional data collections to be performed annually in order to allow us to determine which clinicians are required to report MIPS data.
Third party intermediaries are required to self-nominate annually. If qualified registries and QCDRs are not required to submit a self-nomination statement on an annual basis, we will have no mechanism to determine which registries and QCDRs will participate in submitting quality measures, improvement activities, or Promoting Interoperability measures, objectives and activities. As such, we would not be able to post the annual list of qualified registries which MIPS eligible clinicians use to select qualified registries and QCDRs to use to report quality measures, improvement activities, or Promoting Interoperability measures, objectives, and activities to CMS.
In the CY 2022 PFS proposed rule, we propose voluntary subgroup reporting for clinicians who choose to report on measures and activities in an MVP, beginning with the CY 2023 MIPS performance period/2025 payment year. If the proposal is finalized, we would need data on the clinicians electing to be part of a subgroup to appropriately assess performance for the clinicians participating as a subgroup. Therefore, in the CY 2022 PFS proposed rule, we propose an annual subgroup registration process in place for that data to be entered. Similarly, we propose a MVP registration process to collect data on individuals, groups, subgroups and APM Entities reporting MVPs beginning in the CY 2023 MIPS performance period/2025 payment year (86 FR 39374 through 39376).
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than 3 years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;
Use a statistical data classification that has not been reviewed and approved by OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
Serving as the 60-day notice, the CY 2022 PFS proposed rule (CMS-1751-P, RIN 0938-AU42) filed for public inspection on July 13, 2021 and published in the Federal Register on July 23, 2021 (86 FR 39104). Public comments must be received no later than 5 p.m. on September 13, 2021.
We will use this data to assess MIPS eligible clinician performance in the MIPS performance categories, calculate the final score, and calculate positive and negative payment adjustments based on the final score. For the APM data collections, the Partial QP election will also be used to determine MIPS eligibility for receiving payment adjustments based on a final score. For the Other Payer Advanced APM determinations, no gift or payment is provided via MIPS; however, information from these determinations may be used to assess whether a clinician participating in Other Payer Advanced APMs meets the thresholds under the All-Payer Combination Option required to receive QP status and the associated APM incentive payment.
More detail on how the payments are calculated can be found in 42 CFR §414.1405 and §414.1450.
Consistent with federal government and CMS policies, CMS will protect the confidentiality of the requested proprietary information. Specifically, any confidential information (as such terms are interpreted under the Freedom of Information Act and the Privacy Act of 1974) will be protected from release by CMS to the extent allowable by law and consistent with 5 U.S.C. 552a(b).
Quality Payment Program (QPP), System No. 09-70-0539 (February 14, 2018; 83 FR 6587).
Other than requested proprietary information noted above in section 10, there are no sensitive questions included in the information request. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2020 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). In this regard, Table 1 presents the mean hourly wage, the cost of fringe benefits and overhead (calculated at 100 percent of salary), and the adjusted hourly wage. The adjusted hourly wage is used to calculate the labor costs.
As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Therefore, we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method. With regard to respondents, we selected BLS occupations Billing and Postal Clerks, Computer Systems Analysts, Physicians (multiple categories), Medical and health services manager, and Licensed Practical Nurse based on a study (Casalino et al., 2016) that collected data on the staff in physician’s practices involved in the quality data submission process.4
We previously used the BLS wage rate for “Physicians and Surgeons” (occupation code 29-1060) to estimate the burden for Physicians. In BLS’ most recent set of occupational wage rates (dated May 2020), they have discontinued this occupation in their wage data. As a result, in order to estimate the burden for Physicians, we are using a rate of $217.32/hr which is the average of the mean wage rates for Anesthesiologists; Family Medicine Physicians; General Internal Medicine Physicians; Obstetricians and Gynecologists; Pediatricians, General; Physicians, All Other; and Ophthalmologists, Except Pediatric; Psychiatrists; and Surgeons, Except Ophthalmologists [($261.00/hr + $206.12/hr + $202.84/hr + $229.92/hr + $177.48/hr + $210.44/hr + $208.76/hr + $241.98/hr) ÷ 8].
TABLE 1: National Occupational Employment and Wage Estimates
Occupation Title |
Occupational Code |
Mean Hourly Wage ($/hr.) |
Fringe Benefits and Overhead costs ($/hr) |
Adjusted Hourly Wage ($/hr) |
Anesthesiologists |
29-1211 |
130.50 |
130.50 |
261.00 |
Billing and Posting Clerks |
43-3021 |
20.01 |
20.01 |
40.02 |
Computer Systems Analysts |
15-1211 |
47.61 |
47.61 |
95.22 |
Family Medicine Physicians |
29-1215 |
103.06 |
103.06 |
206.12 |
General Internal Medicine Physicians |
29-1216 |
101.42 |
101.42 |
202.84 |
Licensed Practical Nurse (LPN) |
29-2061 |
24.08 |
24.08 |
48.16 |
Medical and Health Services Managers |
11-9111 |
57.12 |
57.12 |
114.24 |
Obstetricians and Gynecologists |
29-1218 |
114.96 |
114.96 |
229.92 |
Pediatricians, General |
29-1221 |
88.74 |
88.74 |
177.48 |
Physicians, All Other; and Ophthalmologists, Except Pediatric |
29-1228 |
105.22 |
105.22 |
210.44 |
Psychiatrists |
29-1223 |
104.38 |
104.38 |
208.76 |
Surgeons, Except Ophthalmologists |
29-1248 |
120.99 |
120.99 |
241.98 |
Because of the wide range of information collection requirements under MIPS, Table 2 presents a framework for understanding how the organizations permitted or required to submit data on behalf of clinicians vary across the types of data, and whether the clinician is a MIPS eligible clinician or other eligible clinician voluntarily submitting data, MIPS APM participant, or an Advanced APM participant. As shown in the first row of Table 2, MIPS eligible clinicians and other clinicians voluntarily submitting data will submit data either as individuals, groups, subgroups, APM Entities or virtual groups for the quality, Promoting Interoperability, and improvement activities performance categories. Note that virtual groups are subject to the same data submission requirements as groups, and therefore, we will refer only to groups for the remainder of this section unless otherwise noted. Because MIPS eligible clinicians are not required to submit any additional information for assessment under the cost performance category, the administrative claims data used for the cost performance category is not represented in Table 2.
For MIPS eligible clinicians participating in MIPS APMs, the organizations submitting data on behalf of MIPS eligible clinicians will vary between performance categories and, in some instances, between MIPS APMs. As discussed in the CY 2022 PFS proposed rule (86 FR 39383 through 39386), for clinicians in APM Entities, the APM Performance Pathway is available for both ACO and non ACOs to submit quality data. Due to data limitations and our inability to determine who would use the APM Performance Pathway versus the traditional MIPS submission mechanism for the CY 2022 MIPS performance period/2024 MIPS payment year, we assume ACO APM Entities will submit data through the APM Performance Pathway, using the CMS Web Interface option, and non-ACO APM Entities would participate through traditional MIPS, thereby submitting as an individual or group rather than as an entity.
For the Promoting Interoperability performance category, group TINs may submit data on behalf of eligible clinicians in MIPS APMs, or eligible clinicians in MIPS APMs may submit data individually. For the improvement activities performance category, we will assume no reporting burden for MIPS APM participants because they will be reporting through the APM Performance Pathway. In the CY 2017 Quality Payment Program final rule, we described that for MIPS APMs, we compare the requirements of the specific MIPS APM with the list of activities in the Improvement Activities Inventory and score those activities in the same manner that they are otherwise scored for MIPS eligible clinicians (81 FR 77185). Although the policy allows for the submission of additional improvement activities if a MIPS APM receives less than the maximum improvement activities performance category score, to date all MIPS APM have qualified for the maximum improvement activities score. Therefore, we assume that no additional submission will be needed.
Eligible clinicians who attain Partial QP status may incur additional burden if they elect to participate in MIPS, which is discussed in more detail in the CY 2018 Quality Payment Program final rule (82 FR 53841 through 53844).
TABLE 2: Clinicians and Organizations Submitting MIPS Data on Behalf of Clinicians by Type of Data*
Clinicians and Organizations |
Quality Performance Category Data |
Promoting Interoperability Performance Category Data |
Improvement Activities Performance Category Data |
Other Data Submitted on Behalf of MIPS Eligible Clinicians |
MIPS Eligible Clinicians and Other Eligible Clinicians Voluntarily Submitting MIPS Data, Participating in Shared Savings Program, and other MIPS APMs that use the APM Performance Pathway for model measures |
As virtual group, group, subgroup, individual clinicians, or APM Entity.a |
As virtual group, group, subgroup, individual clinicians, or APM Entity.
Certain MIPS eligible clinicians are automatically eligible for a zero percent weighting for the Promoting Interoperability performance category (please refer to the CY 2020 PFS final rule for a summary of the finalized criteria (84 FR 63111)).
Clinicians who submit an application and are approved for significant hardship or other exceptions are also eligible for a zero percent weighting.
Each MIPS eligible clinician in the APM Entity reports data for the Promoting Interoperability performance category through either group TIN or individual reporting. [The burden estimates for this final rule assume group TIN-level reporting].b |
As virtual group, group, subgroup, or individual clinicians.
MIPS APMs do not submit information.
CMS will assign the same improvement activities performance category score to each APM Entity based on the activities involved in participation in the MIPS APM.c |
Groups electing to use a CMS-approved survey vendor to administer CAHPS must register.
Groups electing to submit via CMS Web Interface for the first time must register.
MVP participants election to submit data for the measures and activities in an MVP must register.
MIPS APMs electing the APM Performance Pathway.
APM Entities will make Partial QP election for participating eligible clinicians.
Virtual groups must register via email.d |
* Because the cost performance category relies on administrative claims data, MIPS eligible clinicians are not required to provide any additional information, and therefore, the cost performance category is not represented in this table.
a Submissions by the ACO are not included in burden estimates for this final rule because quality data submissions to fulfill requirements of the Shared Savings Program are not subject to the PRA. Sections 1899 (42 U.S.C. 1395jjj) state that the Shared Savings Program is not subject to the PRA.
b Both group TIN and individual clinician Promoting Interoperability data will be accepted. If both group TIN and individual scores are available for the same APM Entity, CMS will use the higher score for each TIN/NPI. The TIN/NPI scores are then aggregated for purposes of calculating the APM Entity score.
c The burden estimates for this final rule assume no improvement activities performance category reporting burden for APM participants because we assume the MIPS APM model provides a maximum improvement activity score. APM Entities participating in MIPS APMs receive an improvement activities performance category score of at least 50 percent (42 CFR 414.1380) and do not need to submit improvement activities data unless the CMS-assigned improvement activities scores are below the maximum improvement activities score.
d Virtual group participation is limited to MIPS eligible clinicians, specifically, solo practitioners and groups consisting of 10 eligible clinicians or fewer.
The policies finalized in the CY 2017 and CY 2018 Quality Payment Program final rules and CY 2019, 2020, and 2021 PFS final rules, and continued in the CY 2022 PFS proposed rule create some additional data collection requirements not listed in Table 2. These additional data collections consist of:
Self-nomination of new and returning QCDRs
Self-nomination of new and returning qualified registries
Open Authorization Credentialing and Token Request Process
Quality Payment Program Identity Management Application Process
Reweighting Applications for Promoting Interoperability and Other Performance Categories
Call for quality measures
Nomination of new improvement activities
Call for Promoting Interoperability measures
Nomination of MVPs
Opt out of performance data display on Physician Compare for voluntary reporters under MIPS
Partial Qualifying APM Participant (Partial QP) election
Other Payer Advanced APM determinations: Payer Initiated Process
Other Payer Advanced APM determinations: Eligible Clinician Initiated Process
Submission of Data for All-Payer QP Determinations Framework for Understanding the Burden of MIPS Data Submission
Under MIPS, the quality, Promoting Interoperability, and improvement activities performance category data may be submitted via relevant third-party intermediaries, such as qualified registries, QCDRs, and health IT vendors. Data on the CAHPS for MIPS survey, which counts as either one quality performance category measure, or towards an improvement activity, can be submitted via CMS-approved survey vendors. Entities seeking approval to submit data on behalf of clinicians as a qualified registry, QCDR, or survey vendor must complete a self-nominate process annually. The processes for self-nomination for entities seeking approval as qualified registries and QCDRs are similar with the exception that QCDRs have the option to nominate QCDR measures for approval for the reporting of quality performance category data. Therefore, differences between QCDRs and qualified registry self-nomination are associated with the preparation of QCDR measures for approval. The burden associated with qualified registry self-nomination and QCDR self-nomination and measure submission follow:
Qualified registries interested in submitting MIPS data to us on their participants’ behalf need to complete a self-nomination process to be considered for approval to do so (82 FR 53815).
Previously approved qualified registries in good standing (i.e., that are not on probation or disqualified) may attest that certain aspects of their previous year's approved self-nomination have not changed and will be used for the applicable performance period. Qualified registries in good standing that would like to make minimal changes to their previously approved self-nomination application from the previous year, may submit these changes, and attest to no other changes from their previously approved qualified registry application for CMS review during the self-nomination period. The self-nomination period is from July 1 to September 1 of the calendar year prior to the applicable performance period.
In the CY 2022 PFS proposed rule (86 FR 39463), we propose that beginning with the CY 2023 qualified registry self-nomination period, qualified registries that have never submitted data since the inception of MIPS (CY 2017 MIPS performance period/2019 MIPS payment year) through the CY 2020 MIPS performance period/2022 MIPS payment year, must submit a participation plan as part of their self-nomination application for CY 2023. Exceptions to this requirement may occur if data is received for the CY 2021 MIPS performance period/2023 MIPS payment year. Under this scenario, qualified registries would not need to submit a participation plan for the 2023 self-nomination process. Under this proposal, the participation plan must explain the qualified registry’s detailed plans about how the vendor intends to encourage clinicians to submit MIPS data to CMS through the third-party intermediary on behalf of clinicians or groups. The vendor must also explain why they should still be allowed to participate as a qualified vendor.
Based on our review of the existing list of approved qualified registries that did not submit performance data since the inception of MIPS (CY 2017 MIPS performance period/2019 MIPS payment year), we estimate that 19 qualified registries will submit participation plans for the CY 2023 MIPS self-nomination period. Similar to our assumptions used for submission of a Corrective Action Plan (CAP) in the CY 2021 PFS final rule (85 FR 84968), we anticipate that the effort involved in developing a participation plan including the proposed policies specified in the CY 2022 PFS proposed rule and submitting it to CMS is likely to be no more than 3 hours for a computer systems analyst at a rate of $95.22/hr. In aggregate, for the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate an annual burden of 57 hours (3 hr x 19 participation plans) at a cost of $5,428 (57 hr x $95.22/hr) for qualified registries to develop and submit a participation plan.
We are adjusting the number of qualified registries we assume will self-nominate for the CY 2022 MIPS performance period/2024 MIPS payment year from the currently approved estimate of 183 to 210, an increase of 27 from the currently approved estimate based on the number of self-nominations received during the CY 2021 self-nomination period. In the CY 2019 PFS final rule, we estimated that the burden per respondent will range from 0.5 hours for the simplified nomination form and 3 hours for a qualified registry to submit all the required information during the full self-nomination process (83 FR 59998). Based on our experience with the self-nomination process, we believe that the number of fields needed to be submitted for a qualified registry are fewer than those needed for a QCDR self-nomination form. We assume that our previous assumption of 3 hours is an overestimate, and we estimate that the time required for a qualified registry submitting a full-self-nomination process will be 2 hours. In aggregate, we to revise the estimated burden per respondent to range from 0.5 hours for the simplified self-nomination form to 2 hours for the full self-nomination form. We estimate that the annual burden will range from 105 hours (210 qualified registries x 0.5 hr) at a cost of $9,998 (105 hr x $95.22/hr) to 420 hours (210 qualified registries x 2 hr) at a cost of $39,992 (420 hr x $95.22/hr).
The burden associated with the qualified registry self-nomination process varies depending on the number of existing qualified registries that elect to use the simplified self-nomination process in lieu of the full self-nomination process as described in the CY 2018 Quality Payment Program final rule (82 FR 53815). The QPP Self-Nomination Form is submitted electronically using a web-based tool. We will be submitting a revised version of the form for approval under OMB control number 0938-1314 (CMS-10621). In section IV.A.3.h.(3)(a)(iii) of the CY 2022 PFS proposed rule, to provide further clarity and to better align with the existing policy described in the CY 2017 Quality Payment Program final rule (81 FR 77366 through 77367; 81 FR 77383 through 77384), we propose to codify the requirement for qualified registries to conduct a randomized audit of a subset of data prior to submission, and the provision of a data validation plan along with the results of the executed data validation plan by May 31 of the year following the performance period .
In the CY 2021 PFS final rule (85 FR 84967), we estimated a range of effort to complete a targeted data audit from a minimum of 5 hours to a maximum of 10 hours at a cost ranging from $476.10 ($95.22/hr x 5 hrs/registry) to $952.20 ($95.22/hr x 10 hrs/registry) per targeted audit. In the CY 2019 MIPS performance period/2021 MIPS payment year, 37 of the 84 qualified registries (44%) that submitted 2019 MIPS quality data were required to complete a targeted audit. Consistent with our assumptions in the CY 2021 PFS final rule (85 FR 84967) and accounting for the estimated increase in the number of qualified registries that would submit self-nomination applications for the CY 2022 self-nomination period, we estimate 63 qualified registries would be required to conduct targeted audits. Therefore, we estimate the total impact associated with qualified registries completing targeted audits will range from 315 hours (63 registries x 5 hr/audit) at a cost of $29,994 (63 registries x $476.10/audit) to 630 hours (63 registries x 10 hr/audit) at a cost of $59,989 (63 registries x $952.20/audit).
Consistent with our assumptions in the CY 2021 PFS final rule (85 FR 84968), we estimate an annual burden of no more than 30 hours (3 hr x 10 respondents) at a cost of $2,857 (30 hr x $95.22/hr) for third party intermediaries to develop and submit a CAP. Because we are unable to predict how many of the estimated 10 third party intermediaries submitting CAPs will be qualified registries, QCDRs, survey vendors, or Health IT vendors; for simplicity we continue to add the burden to the currently approved burden for qualified registries.
We assume that the staff involved in the qualified registry self-nomination process will continue to be computer systems analysts or their equivalent, who have an average labor rate of $95.22/hr. Considering that the time per qualified registry associated with the self-nomination process ranges from a minimum of 0.5 hours to a maximum of 2 hours, we estimate that the annual burden will range from 105 hours (210 qualified registries x 0.5 hr) to 420 hours (210 qualified registries x 2 hr) at a cost ranging from $9,998 (105 hr x $95.22/hr) and $39,992 (420 hr x $95.22/hr), respectively (see Table 3). Combined with our estimates of burden associated with completing targeted audits, and developing and submitting a CAP and participation plan, our total burden estimate ranges from 507 hours (105 hr + 315 hr + 30 hr + 57hr) to 1,137 (420 hr + 630 hr + 30 hr + 57 hr) at a cost between $48,277 ($9,998 + $29,994 + $2,857 + $5,428) and $108,266 ($39,992 + $59,989 + $5,428 + $2,857).
Qualified registries must comply with requirements on the submission of MIPS data to CMS. The burden associated with qualified registry submission requirements will be the time and effort associated with calculating quality measure results from the data submitted to the qualified registry by its participants and submitting these results, the numerator and denominator data on quality measures, the Promoting Interoperability performance category, and improvement activities data to us on behalf of their participants. We expect that the time needed for a qualified registry to accomplish these tasks will vary along with the number of MIPS eligible clinicians submitting data to the qualified registry and the number of applicable measures. However, we believe that qualified registries already perform many of these activities for their participants. Therefore, we believe the estimates discussed earlier and as shown in Table 3, the 1,137-hour estimate represents the upper bound for qualified registry burden, with the potential for less additional MIPS burden if the qualified registry already provides similar data submission services.
Based on these assumptions, we provide an estimate of the total annual burden associated with a qualified registry self-nominating to be considered for approval.
TABLE 3: Estimated Burden for Qualified Registry Self-Nomination
Burden and Respondent Descriptions |
Minimum Burden Estimate |
Maximum Burden Estimate |
# of Qualified Registry Simplified Self-Nomination Applications submitted (a) |
210 |
0 |
# of Qualified Registry Full Self-Nomination Applications submitted (b) |
0 |
210 |
Total Applications (c) |
210 |
210 |
Total Annual Hours Per Qualified Registry for Simplified Process (d) |
0.5 |
0 |
Total Annual Hours Per Qualified Registry for Full Process (e) |
0 |
2 |
Total Annual Hours for Self-Nomination for min. (f) = (a) * (d) and max. (b) * (e) |
105 |
420 |
Total Annual Hours for Completion of 63 Targeted Audits (g) |
315 |
630 |
Total Annual Hours for development and submittal of 19 Participation Plans (h) |
57 |
57 |
Total Annual Hours for Submittal of 10 CAPs (i) |
30 |
30 |
Total Annual Time (Hours) (j) = (e) + (f) + (g) + (h) |
507 |
1,137 |
Cost Per Simplified Process Per Qualified Registry (@ computer systems analyst’s labor rate of $95.22/hr) (k) |
$47.61 |
$47.61 |
Cost Per Full Process Per Qualified Registry (@ computer systems analyst’s labor rate of $95.22/hr) (l) |
$190.44 |
$190.44 |
Cost Per Targeted Audit (@ computer systems analyst’s labor rate of $95.22/hr) (m) |
$476.10 |
$952.20 |
Cost Per Participation Plan (@ computer systems analyst’s labor rate of $95.22/hr) (n) |
$285.66 |
$285.66 |
Cost per CAP (@ computer systems analyst’s labor rate of $95.22/hr) (o) |
$285.66 |
$285.66 |
Total Annual Cost for min. (p) = (a) * (k) + (m) * 63 + (n) * 19 + (o) * 10 and max. (b) * (l) + (m) * 63 + (n) * 19 + (o) * 10 |
$48,277 |
$108,266 |
QCDRs interested in submitting quality, Promoting Interoperability, and improvement activities performance category data to us on their participants’ behalf will need to complete a self-nomination process to be considered for approval to do so.
Previously approved QCDRs in good standing (that are not on probation or disqualified) that wish to self-nominate using the simplified process can attest, in whole or in part, that their previously approved form is still accurate and applicable. Existing QCDRs in good standing that would like to make minimal changes to their previously approved self-nomination application from the previous year, may submit these changes, and attest to no other changes from their previously approved QCDR application. The self-nomination period is from July 1 to September 1 of the calendar year prior to the applicable performance period (83 FR 59898).
In the CY 2022 PFS proposed rule (86 FR 39463), we propose identical requirements related to the submission of participation plans for QCDRs that have never submitted data since the inception of MIPS (CY 2017 MIPS performance period/2025 MIPS payment year), as previously discussed for qualified registries.
Based on our review of the existing list of approved QCDRs that did not submit performance data since the inception of MIPS (CY 2017 MIPS performance period/2019 MIPS payment year), we estimate that approximately 10 QCDRs will submit participation plans for the CY 2022 self-nomination period. Similar to our assumptions for submission of a Corrective Action Plan (CAP) in the CY 2021 PFS final rule (85 FR 84968), we anticipate that the effort involved in developing a participation plan including the proposed policies specified in the CY 2022 PFS proposed rule and submitting it to CMS is likely to be no more than 3 hours for a computer systems analyst at a rate of $95.22/hr. For the CY 2022 MIPS performance period/2024 MIPS payment year, we estimate an annual burden of 30 hours (3 hr x 10 participation plans) at a cost of $2,857 (30 hr x $95.22/hr) for QCDRs that would need to develop and submit a participation plan.
In the CY 2021 PFS final rule (85 FR 84967), we estimated a range of effort to complete a targeted data audit from a minimum of 5 hours to a maximum of 10 hours at a cost ranging from $476.10 ($95.22/hr x 5 hrs) to $952.20 ($95.22/hr x 10 hrs) per targeted audit. In the CY 2019 MIPS performance period/2021 MIPS payment year, 23 of the 77 QCDRs (30%) that submitted 2019 MIPS quality data were required to complete a targeted audit. Based on the estimated number of self-nomination applications for the 2021 self-nomination period, we estimate that 20 QCDRs will submit targeted audits for the CY 2022 MIPS performance period/2024 MIPS payment year. an increase of 3 from the currently approved estimate of 17 QCDRs submitting targeted audits in the CY 2021 PFS final rule. Therefore, we estimate the total impact associated with QCDRs completing targeted audits will range from 100 hours (20 audits x 5 hr/audit) at a cost of $9,522 (20 audits x $476.10/audit) to 200 hours (20 audits x 10 hr/audit) at a cost of $19,044 (20 audits x $952.20/audit).
We are adjusting the number of QCDRs we assume will self-nominate for the CY 2022 performance period from the currently approved estimate of 82 to 90, an increase of 8 from the currently approved estimate based on the number of self-nominations received during the CY 2021 self-nomination period. In the CY 2021 PFS final rule, we estimated that the burden per respondent will range from 5.5 hours for the simplified self-nomination form to 8 hours for the full self-nomination form. Based on our experience with the amount of time needed for QCDRs during the 2020 self-nomination period, we assume that the estimated time of 3 hours per QCDR for a full self-nomination process is an overestimate and are proposing to revise our estimated time required for the QCDR full-self-nomination process to 2.5 hours, a decrease of 0.5 hours. We estimate that the self-nomination process for QCDRs to submit on behalf of MIPS eligible clinicians or groups for MIPS will involve approximately 2.5 hours per QCDR to submit information required at the time of self-nomination as described in the CY 2017 Quality Payment Program final rule including basic information about the QCDR, describing the process it will use for completion of a randomized audit of a subset of data prior to submission, providing a data validation plan, and providing results of the executed data validation plan by May 31 of the year following the performance period (81 FR 77383 through 77384). We are not making any adjustments in the amount of time needed for simplified self-nomination process. The burden associated with QCDR self-nomination will vary depending on the number of existing QCDRs that will elect to use the simplified self-nomination process in lieu of the full self-nomination process as described in the CY 2018 Quality Payment Program final rule (82 FR 53808 through 53813). The QPP Self-Nomination Form is submitted electronically using a web-based tool.
QCDRs must calculate their measure results and also must possess benchmarking capabilities (for QCDR measures) that compare the quality of care a MIPS eligible clinician provides with other MIPS eligible clinicians performing the same quality measures. For QCDR measures, the QCDR must provide to us, if available, data from years prior (for example, 2017 data for the 2019 MIPS performance period) before the start of the performance period. In addition, the QCDR must provide to us, if available, the entire distribution of the measure’s performance broken down by deciles. As an alternative to supplying this information to us, the QCDR may post this information on their website prior to the start of the performance period, to the extent permitted by applicable privacy laws. The time it takes to perform these functions may vary depending on the sophistication of the entity, but we estimate that a QCDR will spend an additional 1 hour performing these activities per measure. QCDRs are also required to link their QCDR measures as feasible to at least one of the following, at the time of self-nomination: (a) cost measures, (b) improvement activities, or (c) MIPS Value Pathways. We estimate that a QCDR will spend an additional 1 hour performing these activities per measure, on average.
Based on the number of QCDR measures submitted at the time of self-nomination for the CY 2021 MIPS performance period/ 2023 MIPS payment year, we assume that 90 QCDRs will submit 1,080 measures for consideration in the CY 2022 MIPS performance period/2024 MIPS payment year, approximately 12 measures per QCDR, on average. We anticipate that out of the 1,080 measures, 900 measures would be existing or borrowed measures, approximately 10 measures submitted per QCDR self-nomination application. The remaining 180 measures would be new measures, approximately 2 measures on average per QCDR. In aggregate, we estimate that each QCDR submitting measures for approval during the self-nomination process will submit approximately 12 measures (10 existing or borrowed measures + 2 new measures); this is an increase of 10 measures from the currently approved estimate of 2 measures per QCDR. The estimated increase in the total number of measures submitted by a QCDR at the time of self-nomination is due to the inclusion of the existing or borrowed QCDR measures in our assumptions. Additionally, we anticipate that less information is needed for a QCDR to submit an existing or borrowed measure for approval, therefore, we estimate that the time needed for a QCDR to submit an existing or borrowed measure is 0.5 hours, independent of the selection of the simplified or full self-nomination process. Consistent with our assumption in the CY 2020 PFS final rule (84 FR 63119), we continue to estimate that each QCDR will require 2 hours to submit a new QCDR measures for approval, independent of the selection of the simplified or full self-nomination process. To account for the difference in the time for submission of new vs existing QCDR measures for approval, we are using the weighted average to estimate the time required for QCDR measure submission at the time of self-nomination. Therefore, we assume that the weighted average of the time required for each QCDR to submit a new or existing or borrowed measure for approval during the self-nomination process is 0.75 hours [((2 new measures × 2 hours) + (10 existing or borrowed measures × 0.5 hours))/total # of measures (12)]. In aggregate, we estimate that a QCDR would require 0.75 hours to submit each QCDR measure for approval, independent of the selection of the simplified or full nomination process. This would result in a decrease of 1.75 hours from the currently approved estimated burden of 2 hours per QCDR measure submission.
For QCDRs that submit measures as part of their self-nomination process, while simultaneously accounting for the estimated increase in the number of existing or borrowed QCDR measures submitted with the self-nomination application and the decrease in the estimated time for the QCDR full-nomination process, we are proposing to revise our estimated time for the QCDR self-nomination process to a minimum of 9.5 hours [0.5 hours for the simplified self-nomination process + (12 measures × 0.75 hr/measure for QCDR measure submission)] and a maximum of 11.5 hours [2.5 hours for the full self-nomination process + (12 measures × 0.75 hr/measure for QCDR measure submission)], an increase of 4 hours and 3.5 hours from the currently approved burden per respondent estimate in the CY 2021 PFS final rule (85 FR 84965) for the simple and full self-nomination process, respectively.
We assume that the staff involved in the QCDR self-nomination process will continue to be computer systems analysts or their equivalent, who have an average labor rate of $95.22/hr. Considering that the time per QCDR associated with the self-nomination process range from a minimum of 9.5 hours to a maximum of 11.5 hours, we estimate that the annual burden will range from 855 hours (90 QCDRs x 9.5 hr) to 1,035 hours (90 QCDRs x 11.5 hr) at a cost ranging from $81,413 (855 hr x $95.22/hr) and $98,553 (1,035 hr x $95.22/hr), respectively. Combined with our estimate of annual burden for targeted audits, and the proposed burden for submission of participation plans, we estimate that the QCDR self-nomination process would range from 985 hours [855 hr (90 QCDRs x 9.5 hr) + 100 hr (20 audits x 5 hr) + 30 hr (10 participation plans x 3 hr)] at a cost of $93,792 [$81,414 (855 hr x $95.22/hr) + $9,522 (20 audits × $476.10/audit) + $2,857 (30 hr x $95.22/hr)] for a simplified self-nomination process to 1,265 hours [1,035 hr (90 QCDRs x 11.5 hr) + 200 hr (20 audits x 10 hr) + 30 hr (10 participation plans x 3 hr)] at a cost of $120,454 [$98,553 (1,035 hr x $95.22 /hr) + $19,044 (20 audits × $952.20/audit) + $2,857 (30 hr x $95.22/hr)] for the full self-nomination process (see Table 4).
QCDRs must comply with requirements on the submission of MIPS data to CMS. The burden associated with the QCDR submission requirements will be the time and effort associated with calculating quality measure results from the data submitted to the QCDR by its participants and submitting these results, the numerator and denominator data on quality measures, the Promoting Interoperability performance category, and improvement activities data to us on behalf of their participants. We expect that the time needed for a QCDR to accomplish these tasks will vary along with the number of MIPS eligible clinicians submitting data to the QCDR and the number of applicable measures. However, we believe that QCDRs already perform many of these activities for their participants. Therefore, we believe the 1,265-hour estimate represents the upper bound of QCDR burden, with the potential for less additional MIPS burden if the QCDR already provides similar data submission services.
Based on the assumptions previously discussed, we provide an estimate of the total annual burden associated with a QCDR self-nominating to be considered for approval.
TABLE 4: Estimated Burden for QCDR Self-Nomination
Burden and Respondent Descriptions |
Minimum Burden Estimate |
Maximum Burden Estimate |
# of QCDR Simplified Self-Nomination Applications submitted (a) |
90 |
0 |
# of QCDR Full Self-Nomination Applications submitted (b) |
0 |
90 |
Total Applications |
90 |
90 |
Total Annual Hours Per QCDR for Simplified Process (c) |
9.5 |
9.5 |
Total Annual Hours Per QCDR for Full Process (d) |
11.5 |
11.5 |
Annual Hours for Self-nomination (e) = (a) * (c) and (b) * (d) |
855 |
1,035 |
# of Hours per Completion of Targeted Audit (f) |
5 |
10 |
Annual Hours for Completion of 20 Targeted Audits (g) |
100 |
200 |
# of Hours per Submission of Participation Plan (h) |
3 |
3 |
Annual Hours for Submission of 10 Participation Plans (i) |
30 |
30 |
Total Annual Time (Hours) (j) |
985 |
1,265 |
Cost Per Simplified Process Per QCDR (@ computer systems analyst’s labor rate of $95.22/hr) (k) = (c) * $95.22/hr |
$904.60 |
$904.60 |
Cost Per Full Process Per QCDR (@ computer systems analyst’s labor rate of $95.22/hr) (l) = (d) * $95.22/hr |
$1,095.03 |
$1,095.03 |
Cost Per Targeted Audit (@ computer systems analyst’s labor rate of $95.22/hr) (m) = (f) * $95.22/hr |
$476.10 |
$952.20 |
Cost Per Participation Plan (@ computer systems analyst’s labor rate of $95.22/hr) (n) = (h) * $95.22/hr |
$285.70 |
$285.70 |
Total Annual Cost (o) = (a) * (k) + (f) * 20 + (n)*10 (min.) and (b)*(l) + (m) * 20 + (n) * 10 (max.) |
$93,792 |
$120,454 |
Beginning with the CY 2021 MIPS performance period/2023 MIPS payment year, the OAuth Credentialing and Token Request Process is available to all submitter types who are approved to submit data via the direct submission type. Individual clinicians or groups may submit their quality measures using the direct submission type via the MIPS CQM, QCDR or eCQM collection types as well as their Promoting Interoperability measures and improvement activities through the same direct submission type. The burden associated with this ICR belongs only to the application developer; QPP participants will not be required to do anything additional to submit their data. For third party intermediaries, OAuth Credentialing will allow QPP participants to use their own QPP credentials to login through the third-party intermediary’s application to submit their data and view performance feedback from QPP. Entities that receive approval for their applications through this process will be able to provide QPP participants a more comprehensive and less administratively burdensome experience using the direct submission type.
For interested parties to submit their request for token process, we estimate that it would take approximately 1 hour at $95.22/hr for a computer systems analyst (or their equivalent) to provide documentation and any follow-up communication via email.
As shown in Table 5, we are not making any changes to our currently approved estimate of 15 submitter types to complete this process for the CY 2022 MIPS performance period/2024 MIPS payment year. In aggregate, we estimate it would take 1 hour at $95.22/hr for a computer systems analyst (or their equivalent) to complete the process. We estimate an annual burden of 15 hours (15 vendors x 1 hr) at a cost of $1,428 (15 hr x $95.22/hr) or $95.22 per organization ($1,428/15 vendors).
TABLE 5: Estimated Burden for the OAuth Credentialing and Token Request Process
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations (a) |
15 |
Total Annual Hours Per Organization to Submit (b) |
1 |
Total Annual Hours (c) = (a)*(b) |
15 |
Cost Per Organization (@ computer systems analyst’s labor rate of $95.22/hr.) (d) |
$95.22/hr |
Total Annual Cost (e) = (a)*(d) |
$1,428 |
Under our current policies, two groups of clinicians must submit quality data under MIPS: those who submit as MIPS eligible clinicians and those who opt to submit data voluntarily but are not subject to MIPS payment adjustments. Clinicians are ineligible for MIPS payment adjustments if they are newly enrolled to Medicare; are QPs; are partial QPs who elect to not participate in MIPS; are not one of the clinician types included in the definition for MIPS eligible clinician; or do not exceed the low-volume threshold as an individual or as a group.
To determine which QPs should be excluded from MIPS, we used the Advanced APM payment and patient percentages from the APM Participant List for the final snapshot date for the 2019 QP performance period. From this data, we calculated the QP determinations as described in the Qualifying APM Participant (QP) definition at § 414.1305 for the 2022 QP performance period. Due to data limitations, we could not identify specific clinicians who have not yet enrolled in APMs, but who may become QPs in the CY 2022 MIPS performance period/2024 MIPS payment year (and therefore will no longer need to submit data to MIPS); hence, our model may underestimate or overestimate the number of respondents.
In the CY 2022 PFS proposed rule (86 FR 39391 through 39392), we propose to extend the CMS Web Interface measures as a collection type/submission type for the CY 2022 MIPS performance period/2024 MIPS payment year. Additionally, we are proposing to sunset the CMS Web Interface measures as a collection type/submission type starting with the CY 2023 MIPS performance period/2025 MIPS payment year. As a result, groups of 25 or more clinicians that previously submitted quality performance data via the CMS Web Interface will be required to use an alternate collection type beginning with the CY 2023 MIPS performance period, which will have to be either the MIPS CQM and QCDR or eCQM collection type. While we know that 111 groups submitted quality performance data via the CMS Web Interface in the CY 2019 MIPS performance period/2021 MIPS payment year, we are not able to ascertain what alternative collection type(s) the groups would elect. In order to estimate the number of groups that will select each of these collection types, we first clustered the number of groups which submitted data via the CMS Web Interface collection type during the CY 2019 MIPS performance period/2021 MIPS payment year by practice size (between 25 and 49 clinicians, between 50 and 99 clinicians, etc.). Then, for each cluster, we allocated these groups to each of the MIPS CQM and QCDR and eCQM collection types based on the percent of TINs that submitted MIPS data via these two collection types. For example, of the 1,629 TINs with a practice size of 25 to 49 clinicians which submitted data for the CY 2019 MIPS performance period/2021 MIPS payment year, 1,066 (65 percent) submitted data via the MIPS CQM and QCDR collection type and 563 (35 percent) submitted data via the eCQM collection type. We applied these percentages to the 7 TINs with a practice size of 25 to 49 clinicians which submitted data via the CMS Web Interface collection type for the CY 2019 MIPS performance period/2021 MIPS payment year to estimate that 4 (7 TINs x 0.56) would elect to submit data via the MIPS CQM and QCDR collection type and the remaining 3 (7 TINs x 0.44) would elect to submit data via the eCQM collection type. In total, beginning with the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate that 64 of the 111 groups that submitted data via the CMS Web Interface collection type for the CY 2019 MIPS performance period/2021 MIPS payment year will submit quality data via the MIPS CQM and QCDR collection type and 50 groups will now submit quality data via the eCQM collection type. Note that the estimate of 114 groups is an increase of 114 from our currently approved estimate of 0 groups for the CY 2022 MIPS performance period/2024 MIPS payment year. We also performed this analysis to determine the number of clinicians that would be affected and would need to submit quality data via an alternate collection type beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. In total, of the estimated 45,599 individual clinicians affected by this provision, we estimate that 11,432 would submit quality data as part of a group via the MIPS CQM and QCDR collection type and 34,167 would submit quality data as part of a group via the eCQM collection type. These respondent estimates are reflected in Tables 6 and 8 and the associated changes in burden are reflected in Tables 11 and 12.
In the CY 2019 PFS final rule, we limited the Medicare Part B claims collection type to small practices beginning with the 2021 MIPS payment year and allowing clinicians in small practices to report Medicare Part B claims as a group or as individuals (83 FR 59752). For the CY 2022 PFS proposed rule, we used 2019 MIPS performance period respondent data.
We assume that 100 percent of ACO APM Entities will submit quality data to CMS as required under their models. While we do not believe there is additional reporting for ACO APM entities, consistent with assumptions used in the CY 2020 and CY 2021 PFS final rules (84 FR 63122 and 85 FR 84972), we include all quality data voluntarily submitted by MIPS APM participants made at the individual or TIN-level in our respondent estimates. As stated in the CY 2022 PFS proposed rule (86 FR 39480), we assume non-ACO APM Entities will participate through traditional MIPS and submit as an individual or group rather than as an entity. To estimate who will be a MIPS APM participant in the CY 2022 and CY 2023 MIPS performance periods/2024 and 2025 MIPS payment years, we used the final snapshot data from the 2019 QP performance period. We elected to use this data source because the APM participant list for the 2019 final snapshot can reliably be used for MIPS APM participant projections. Based on this information, if we determine that a MIPS eligible clinician will not be scored as a MIPS APM, then their reporting assumption is based on their reporting as a group or individual for the CY 2019 MIPS performance period/2021 MIPS payment year.
Our burden estimates for the quality performance category do not include the burden for the quality data that APM Entities submit to fulfill the requirements of their APMs. The burden is excluded as sections 1899(e) (42 U.S.C. 1395jjj(e)) state that the Shared Savings Program is not subject to the PRA. Tables 6, 7, and 8 explain our revised estimates of the number of organizations (including groups, virtual groups, and individual MIPS eligible clinicians) submitting data on behalf of clinicians segregated by collection type.
Tables 6A and 6B provides our estimated counts of clinicians that will submit quality performance category data as MIPS individual clinicians or groups in the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years based on data from the CY 2019 MIPS performance period/2021 MIPS payment year.
For the CY 2022 MIPS performance period/2024 MIPS payment year, respondents will have the option to submit quality performance category data via Medicare Part B claims, direct, and log in and upload submission types, and Web Interface. For the CY 2023 MIPS performance period/2025 MIPS payment year, respondents will no longer have the option to submit quality performance category data via the Web Interface. We estimate the burden for collecting data via collection type: Medicare Part B claims, QCDR and MIPS CQMs, eCQMs, and the CMS Web Interface. We believe that, while estimating burden by submission type may be better aligned with the way clinicians participate with the Quality Payment Program, it is more important to reduce confusion and enable greater transparency by maintain consistency with previous rulemaking.
For the CY 2023 MIPS performance period/2025 MIPS payment year, we propose in the CY 2022 PFS proposed rule that clinicians in MIPS would have the option to submit measures and activities in MVPs. We refer readers to the CY 2022 PFS proposed rule for additional details on the proposed reporting requirements for MVPs (86 FR 39367 through 39371). For the quality performance category of MVPs, we assume that MVP Participants would choose to report via the Medicare Part B claims, QCDR, MIPS CQMs, and eCQMs collection type. Table 15 of the CY 2022 PFS proposed rule includes the estimated burden for collecting data for the quality performance category of MVPs.
Tables 6A and 6B shows that, using participation data from the CY 2019 MIPS performance period/2021 MIPS payment year combined with the estimate of QPs for the CY 2022 MIPS performance period/2024 MIPS payment year, we estimate a total of 625,703 clinicians will submit quality data as individuals or groups in each of the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years, a decrease of 25,811 clinicians when compared to our estimate of 651,514 clinicians in the CY 2021 PFS final rule (85 FR 84972). For the CY 2022 MIPS performance period/2024 MIPS payment year, we estimate 28,252 clinicians will submit data as individuals for the Medicare Part B claims collection type; 279,247 clinicians will submit data as individuals or as part of groups for the MIPS CQM and QCDR collection type; 273,819 clinicians will submit data as individuals or as part of groups via eCQM collection types; and 44,385 clinicians will submit as part of groups via the CMS Web Interface. For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate 25,427 clinicians will submit data as individuals for the Medicare Part B claims collection type; 288,637 clinicians will submit data as individuals or as part of groups for the MIPS CQM and QCDR collection type; 311,326 clinicians will submit data as individuals or as part of groups via the eCQM collection type.
Tables 6A and 6B provide estimates of the number of clinicians to collect quality measures data via each collection type, regardless of whether they decide to submit as individual clinicians or as part of groups for the CY 2022 and CY 2023 MIPS performance periods/2024 and 2025 MIPS payment years, respectively. Because our burden estimates for quality data submission assume that burden is reduced when clinicians elect to submit as part of a group, we also separately estimate the expected number of clinicians to submit as individuals or part of groups.
TABLE 6A: Estimated Number of Clinicians Submitting Quality Performance Category Data by Collection Type, CY 2022 MIPS Performance Period/2024 MIPS Payment Year
Data Description |
Claims |
QCDR/MIPS CQM |
eCQM |
CMS Web Interface |
Total |
2022 MIPS performance period (excludes QPs) (a) |
28,252 |
279,247 |
273,819 |
44,385 |
625,703 |
*Currently approved 2022 MIPS performance period (excludes QPs) (b) |
29,273 |
295,941 |
326,300 |
0 |
651,514 |
Difference (c)=(a)-(b) |
-1,021 |
-16,694 |
-52,481 |
+44,385 |
TABLE 6B: Estimated Number of Clinicians Submitting Quality Performance Category Data by Collection Type, CY 2023 MIPS Performance Period/2025 MIPS Payment Year
Data Description |
Claims |
QCDR/MIPS CQM |
eCQM |
CMS Web Interface |
Total |
2023 MIPS performance period prior to MVP and Web Interface adjustments (excludes QPs) (a) |
28,252 |
295,941 |
326,300 |
0 |
650,493 |
Adjustment for Web Interface Sunset (b) |
0 |
24,767 |
19,618 |
0 |
44,385 |
Adjustment for Shift to MVP (10% reduction) (c) = ((a) + (b)) * -.1 |
-2,825 |
-32,071 |
-34,592 |
0 |
-69,488 |
2023 after adjustments (d) = (a) + (b) + (c) |
25,427 |
288,637 |
311,326 |
0 |
625,390 |
* Currently approved 2022 MIPS performance period (excludes QPs) (e) |
29,273 |
295,941 |
326,300 |
0 |
651,514 |
Difference (f)=(d)-(e) |
-3,846 |
-7,304 |
-14,974 |
0 |
-26,124 |
*Currently approved by OMB under control number 0938-1314 (CMS-10621) from the CY 2021 PFS final rule.
Because MIPS eligible clinicians may submit data for multiple collection types for a single performance category, the estimated numbers of individual clinicians and groups to collect via the various collection types are not mutually exclusive and reflect the occurrence of individual clinicians or groups that collected data via multiple collection types during the CY 2019 MIPS performance period/2021 MIPS payment year. We captured the burden of any eligible clinician that may have historically collected via multiple collection types, as we assume they will continue to collect via multiple collection types and that our MIPS scoring methodology will take the highest score where the same measure is submitted via multiple collection types.
Tables 7A and 7B use methods similar to those described to estimate the number of clinicians that will submit data as individual clinicians via each collection type in the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years, respectively. For the CY 2022 MIPS performance period/2024 MIPS payment year, we estimate that approximately 28,252 clinicians will submit data as individuals using the Medicare Part B claims collection type; approximately 40,507 clinicians will submit data as individuals using MIPS CQM and QCDR collection type; and approximately 40,446 clinicians will submit data as individuals using eCQMs collection type. Based on data from the CY 2019 MIPS performance period/2021 MIPS payment year, these are decreases these are decreases of -1,021, -833, and -1,809 respondents from the currently approved estimates of 29,273, 41,340, and 42,255 for the Medicare Part B claims, MIPS CQM and QCDR, and eCQM collection types, respectively.
For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate that approximately 25,427 clinicians will submit data as individuals using the Medicare Part B claims collection type; approximately 36,456 clinicians will submit data as individuals using MIPS CQM and QCDR collection type; and approximately 36,401 clinicians will submit data as individuals using eCQMs collection type. Based on performance data from the CY 2019 MIPS performance period/2021 MIPS payment year, these are decreases of -3,846, -4,884, and -5,854 respondents from the currently approved estimates of 29,273, 41,340, and 42,255 for the Medicare Part B claims, MIPS CQM and QCDR, and eCQM collection types, respectively.
TABLE 7A: Estimated Number of Clinicians Submitting Quality
Performance
Category Data as Individuals by
Collection Type, CY 2022 MIPS Performance Period/2024
MIPS Payment Year
Data Description |
Claims |
QCDR/MIPS CQM |
eCQM |
CMS Web Interface |
Total |
2022 MIPS Performance Period (excludes QPs) (a) |
28,252 |
40,507 |
40,446 |
0 |
109,205 |
* Currently approved 2022 MIPS Performance Period (excludes QPs) (b) |
29,273 |
41,340 |
42,255 |
0 |
112,868 |
Difference (c)=(a)-(b) |
-1,021 |
-833 |
-1,809 |
0 |
-3,663 |
TABLE 7B: Estimated Number of Clinicians Submitting Quality
Performance
Category Data as Individuals by
Collection Type, CY 2023 MIPS Performance Period/2025 MIPS Payment
Year
Data Description |
Claims |
QCDR/MIPS CQM |
eCQM |
CMS Web Interface |
Total |
2023 MIPS performance period (excludes QPs) (a) |
28,252 |
40,507 |
40,446 |
0 |
109,205 |
MVP adjustment (10% reduction) (b) = (a)*- 0.1 |
-2,825 |
4,051 |
-4,044 |
0 |
-10,920 |
2023 MIPS Performance Period (excludes QPs) (c) = (a) + (b) |
25,427 |
36,456 |
36,401 |
0 |
98,285 |
* Currently approved 2022 MIPS performance period (excludes QPs) (d) |
29,273 |
41,340 |
42,555 |
0 |
112,868 |
Difference (e)=(c)-(d) |
-3,846 |
-4,884 |
-5,854 |
0 |
-14,583 |
*Currently approved by OMB under control number 0938-1314 (CMS-10621).
Consistent with the policy finalized in the CY 2018 Quality Payment Program final rule that for MIPS eligible clinicians who collect measures via Medicare Part B claims, MIPS CQM, eCQM, or QCDR collection types and submit more than the required number of measures (82 FR 53735 through 54736), we will score the clinician on the required measures with the highest assigned measure achievement points and thus, the same clinician may be counted as a respondent for more than one collection type. Therefore, our columns in Table 7 are not mutually exclusive.
Tables 8A and 8B provide our estimated counts of groups or virtual groups that will submit quality data on behalf of clinicians for each collection type in the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years, respectively. We assume that groups that submitted quality data as groups in the CY 2019 MIPS performance period/2021 MIPS payment year will continue to submit quality data either as groups or virtual groups for the same collection types as they did as a group or TIN within a virtual group for the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years. Specifically, for the CY 2022 MIPS performance period/2024 MIPS payment year, we estimate that 11,529 groups and virtual groups will submit data for the MIPS CQM and QCDR collection type, 8,127 groups and virtual groups will submit for eCQM collection types, and 114 groups will submit data via the CMS Web Interface. These are decreases of -75 and -93 respondents from the currently approved estimates of 11,604, and 8,220 groups and virtual groups for the MIPS CQM and QCDR and eCQM collection types, and an increase of +114 groups from the currently approved estimates of 0 groups for the CMS Web Interface collection types, respectively. For the CY 2023 MIPS performance period/2025 MIPS payment year we estimate that 10,434 groups and virtual groups will submit data for the MIPS CQM and QCDR collection type, and 7,359 groups and virtual groups will submit for eCQM collection types. These are decreases of -1,170 and -861 respondents from the currently approved estimates of 11,604, and 8,220 groups and virtual groups for the MIPS CQM and QCDR and eCQM collection types, respectively. The reason for the difference in estimated number of respondents from the estimates for the CY 2022 MIPS performance period/2024 MIPS payment year describe above, is due to the sunset of the CMS Web Interface as a collection type and the implementation of MVPs beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. In the CY 2021 PFS final rule, we finalized the APM Performance Pathway, an alternate measure set consisting of the CMS Web Interface measures for the CY 2021 MIPS performance period/2023 MIPS payment year (85 FR 84859 through 84864). We assume ACO APM Entities will submit data through the APM Performance Pathway and non-ACO APM Entities would participate through traditional MIPS and base our estimates on submissions received in the CY 2019 MIPS performance period/2021 MIPS payment year.
TABLE 8A: Estimated Number of Groups and Virtual Groups Submitting Quality Performance Category Data by Collection Type on Behalf of Clinicians, CY 2022 MIPS Performance Period/2024 MIPS Payment Year
Data Description |
Claims |
QCDR/MIPS CQM |
eCQM |
CMS Web Interface |
Total |
2022 MIPS performance period (excludes QPs) (a) |
0 |
11,529 |
8,127 |
114 |
19,770 |
*Currently approved 2022 MIPS performance period (b) |
0 |
11,604 |
8,220 |
0 |
19,824 |
Difference (c)=(a)-(b) |
0 |
-75 |
-93 |
+114 |
-54 |
TABLE 8B: Estimated Number of Groups and Virtual Groups Submitting Quality Performance Category Data by Collection Type on Behalf of Clinicians, CY 2023 MIPS Performance Period/2025 MIPS Payment Year
Data Description |
Claims |
QCDR/ |
eCQM |
CMS Web Interface |
Total |
2023 MIPS performance period (excludes QPs) (a) |
0 |
11,529 |
8,127 |
114 |
19,770 |
Adjustment for Web Interface (b) |
0 |
64 |
50 |
-114 |
0 |
Adjustment for MVPs (10%) (c) = (a) + (b) * 0.1 |
0 |
-1,159 |
-817.7 |
0 |
-1,977 |
2023 MIPS performance period (excludes QPs) – Adjusted. (d) = (a) + (b) + (c) |
0 |
10,434 |
7,359 |
0 |
17,793 |
* Currently approved 2022 MIPS performance period (excludes QPs) (e) |
0 |
11,604 |
8,220 |
0 |
19,824 |
Difference (f)=(d)-(e) |
0 |
-1,170 |
-861 |
0 |
-2,031 |
*Currently approved by OMB under control number 0938-1314 (CMS-10621) from the CY 2021 PFS final rule.
The burden associated with the submission of quality performance category data have some limitations. We believe it is difficult to quantify the burden accurately because clinicians and groups may have different processes for integrating quality data submission into their practices’ workflows. Moreover, the time needed for a clinician to review quality measures and other information, select measures applicable to their patients and the services they furnish, and incorporate the use of quality measures into the practice workflows is expected to vary along with the number of measures that are potentially applicable to a given clinician’s practice and by the collection type. For example, clinicians submitting data via the Medicare Part B claims collection type need to integrate the capture of quality data codes for each encounter whereas clinicians submitting via the eCQM collection types may have quality measures automated as part of their EHR implementation.
We believe the burden associated with submitting quality measures data will vary depending on the collection type selected by the clinician, group, or third-party. As such, we separately estimated the burden for clinicians, groups, and third parties to submit quality measures data by the collection type used. For the purposes of our burden estimates for the Medicare Part B claims, MIPS CQM and QCDR, and eCQM collection types, we also assume that, on average, each clinician or group will submit 6 quality measures. In the CY 2022 PFS proposed rule, we propose that except as provided in paragraph § 414.1365(c)(1)(i), an MVP Participant must select and report 4 quality measures, including 1 outcome measure (or, if an outcome measure is not available, 1 high priority measure, included in the MVP.
For an individual, group, or third-party to submit MIPS quality, improvement activities, or Promoting Interoperability performance category data using either the log in and upload or the log in and attest submission type or to access feedback reports, the submitter must have a CMS Healthcare Quality Information System (HCQIS) Access Roles and Profile (HARP) system user account. Once the user account is created, registration is not required again for future years.
Based on our assumption that the number of eligible clinicians, groups, or third parties that will register for new accounts will not change substantially from the CY 2019 MIPS performance period/2021 MIPS payment year, our estimate of 3,741 new TINs remains unchanged. As shown in Table 9, it would take 1 hour at $95.22/hr for a computer systems analyst (or their equivalent) to obtain an account for the HARP system. In aggregate we estimate an annual burden of 3,741 hours (3,741 registrations x 1 hr/registration) at a cost of $356,218 (3,741 hr x $95.22/hr) or $95.22 per registration.
TABLE 9: Estimated Burden for Quality Payment Program Identity Management Application Process
Burden and Respondent Descriptions |
Burden Estimate |
# of New TINs completing the Identity Management Application Process (a) |
3,741 |
Total Hours Per Application (b) |
1 |
Total Annual Hours for completing the Identity Management Application Process (c) = (a)*(b) |
3,741 |
Cost Per Application @ computer systems analyst’s labor rate of $95.22/hr.) (d) |
$95.22 |
Total Annual Cost for completing the Identity Management Application Process (e) = (a)*(d) |
$356,218 |
As noted in Table 10 based on CY 2019 MIPS performance period/2021 MIPS payment year data, we assume that 28,252 individual clinicians will collect and submit quality data via the Medicare Part B claims collection type, a decrease of 1,021 from the currently approved estimate of 29,273 respondents based on more recent data and our methodology of accounting only for clinicians in small practices who submitted such claims data in the CY 2019 MIPS performance period/2021 MIPS payment year rather than all clinicians who submitted quality data codes to us for the Medicare Part B claims collection type.
As shown in Table 10, consistent with our currently approved per response time figures, we estimate that the burden of quality data submission using Medicare Part B claims will range from 0.15 hours (9 minutes) at a cost of $14.28 (0.15 hr x $95.22/hr) to 7.2 hours at a cost of $685.58 (7.2 hr x $95.22/hr). The burden will involve becoming familiar with MIPS quality measure specifications. We believe that the start-up cost for a clinician’s practice to review measure specifications is 7 hours, consisting of 3 hours at $114.24/hr for a medical and health services manager, 1 hour at $217.32/hr for a physician, 1 hour at $48.16/hr for an LPN, 1 hour at $95.22/hr for a computer systems analyst, and 1 hour at $40.02/hr for a billing and posting clerk. We are not revising our currently approved per response time estimates.
The estimate for reviewing and incorporating measure specifications for the claims collection type is higher than that of QCDRs/Registries or eCQM collection types due to the more manual, and therefore, more burdensome nature of Medicare Part B claims measures.
For the CY 2022 MIPS performance period/2024 MIPS payment year, considering both data submission and start-up requirements, the estimated time (per clinician) ranges from a minimum of 7.15 hours (0.15 hr + 7 hr) to a maximum of 14.2 hours (7.2 hr + 7 hr). In this regard the total annual time ranges from 202,002 hours (7.15 hr x 28,252 clinicians) to 401,178 hours (14.2 hr x 28,252 clinicians). The estimated annual cost (per clinician) ranges from $758 [(0.15 hr x $95.22/hr) + (3 hr x $114.24/hr) + (1 hr x $95.22/hr) + (1 hr x $48.16/hr) + (1 hr x $40.02/hr) + (1 hr x $217.32/hr)] to a maximum of $1,429 [(7.2 hr x $95.22/hr) + (3 hr x $114.24/hr) + (1 hr x $95.22/hr) + (1 hr x $48.16/hr) + (1 hr x $40.02/hr) + (1 hr x $217.32/hr)]. The total annual cost ranges from a minimum of $21,407,105 (28,252 clinicians x $758) to a maximum of $40,372,673 (28,252 clinicians x $1,429).
For purposes of calculating total burden associated with the Claims collection type for the CY 2023 MIPS performance period/2025 MIPS payment year, only the maximum burden is used. The decrease in the number of annual respondents results in an estimated total annual time of 361,063 hours (14.2 hr x 25,427 clinicians) for the CY 2023 MIPS performance period/2025 MIPS payment year. Using the currently approved unchanged estimate for cost per respondent, the total annual cost for the CY 2023 MIPS performance period/2025 MIPS payment year is $36,335,692 (25,427 clinicians x $1,429 per respondent).
Table 10 summarizes the range of total annual burden associated with clinicians submitting quality data via Medicare Part B claims for both the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years.
TABLE 10: Estimated Burden for Quality Performance Category:
Clinicians Using the Claims Collection Type
Burden and Respondent Descriptions |
Minimum Burden Estimate |
Median Burden Estimate |
Maximum Burden Estimate (2022 Performance Period) |
Maximum Burden Estimate (2023 Performance Period) |
# of Clinicians (a) |
28,252 |
28,252 |
28,252 |
25,427 |
Hours Per Clinician to Submit Quality Data (b) |
0.15 |
1.05 |
7.2 |
7.2 |
# of Hours Medical and health services manager Review Measure Specifications (c) |
3 |
3 |
3 |
3 |
# of Hours Computer Systems Analyst Review Measure Specifications (d) |
1 |
1 |
1 |
1 |
# of Hours LPN Review Measure Specifications (e) |
1 |
1 |
1 |
1 |
# of Hours Billing Clerk Review Measure Specifications (f) |
1 |
1 |
1 |
1 |
# of Hours Clinician Review Measure Specifications (g) |
1 |
1 |
1 |
1 |
Annual Hours per Clinician (h) = (b)+(c)+(d)+(e)+(f)+(g) |
7.15 |
8.05 |
14.2* |
14.2* |
Total Annual Hours (i) = (a)*(h) |
202,002 |
227,429 |
401,178 |
361,063 |
Cost to Submit Quality Data (@ computer systems analyst’s labor rate of $95.22/hr @ varying times) (j) |
$14.28 |
$99.98 |
$685.58 |
$685.58 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $114.24/hr @ 3 hr) (k) |
$342.72 |
$342.72 |
$342.72 |
$342.72 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $95.22/hr @ 1 hr) (l) |
$95.22 |
$95.22 |
$95.22 |
$95.22 |
Cost to Review Measure Specifications (@ LPN's labor rate of $48.16/hr @1 hr) (m) |
$48.16 |
$48.16 |
$48.16 |
$48.16 |
Cost to Review Measure Specifications (@ billing clerk’s labor rate of $40.02/hr @ 1 hr) (n) |
$40.02 |
$40.02 |
$40.02 |
$40.02 |
Cost to Review Measure Specifications (@ physician’s labor rate of $217.32/hr @ 1 hr) (o) |
$217.32 |
$217.32 |
$217.32 |
$217.32 |
*Total Annual Cost Per Clinician (p) = (j)+(k)+(l)+(m)+(n)+(o) |
$758 |
$843 |
$1,429 |
$1,429 |
*Total Annual Cost (q) = (a)*(p) |
$21,407,105 |
$23,828,302 |
$40,372,673* |
$36,355,692* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
In the CY 2022 PFS proposed rule, we propose to extend the CMS Web Interface as a collection type and submission type for the CY 2022 MIPS performance period/2024 MIPS payment year. In the CY 2022 PFS proposed rule, we also propose to sunset the CMS Web Interface measures as a collection type and submission type starting with the CY 2023 MIPS performance period/2025 MIPS payment year. Using the methodology previously described, for the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate 45 additional groups will submit quality data via the MIPS CQM and QCDR collection type due to the sunsetting of the CMS Web Interface measures as a collection type/submission type beginning with the CY 2023 MIPS performance period/2025 MIPS payment year.
As noted in Tables 6A, 7A, and 8A, and based on CY 2019 MIPS performance period/2021 MIPS payment year data, we assume that 40,507 individual clinicians and 11,527 groups and virtual groups will submit quality data for the MIPS CQM and QCDR collection types in the CY 2022 MIPS performance period/2024 MIPS payment year. Due to the proposed policy for implementation of voluntary MVP reporting in the CY 2022 PFS proposed rule, for the CY 2023 MIPS performance period/2025 MIPS payment year, we assume that 36,456 individual clinicians and 10,432 groups and virtual groups will submit quality data using the MIPS CQM or QCDR collection types. Given that the number of measures required is the same for clinicians and groups, we expect the burden to be the same for each respondent collecting data via MIPS CQM or QCDR, whether the clinician is participating in MIPS as an individual or group.
Under the MIPS CQM and QCDR collection types, the individual clinician or group may either submit the quality measures data directly to us, log in and upload a file, or utilize a third-party intermediary to submit the data to us on the clinician’s or group’s behalf.
We estimate that the burden associated with the QCDR collection type is similar to the burden associated with the MIPS CQM collection type; therefore, we discuss the burden for both together below. For MIPS CQM and QCDR collection types, we estimate an additional time for respondents (individual clinicians and groups) to become familiar with MIPS quality measure specifications and, in some cases, specialty measure sets and QCDR measures. Therefore, we believe that the burden for an individual clinician or group to review measure specifications and submit quality data total 9.08 hours at a cost of $922.76 per response. This consists of 3 hours at $95.22/hr for a computer systems analyst (or their equivalent) to submit quality data along with 2 hours at $114.24/hr for a medical and health services manager, 1 hour at $95.22/hr for a computer systems analyst, 1 hour at $48.16/hr for a LPN, 1 hour at $40.02/hr for a billing clerk, and 1 hour at $217.32/hr for a physician to review measure specifications. Additionally, clinicians and groups who do not submit data directly will need to authorize or instruct the qualified registry or QCDR to submit quality measures’ results and numerator and denominator data on quality measures to us on their behalf. We estimate that the time and effort associated with authorizing or instructing the quality registry or QCDR to submit this data will be approximately 5 minutes (0.083 hours) at $95.22/hr for a computer systems analyst at a cost of $7.90 (0.083 hr x $95.22/hr). Overall, we estimate a cost of $922.76/response [(3 hr x $95.22/hr) + (2 hr x $114.24/hr) + (1 hr x $217.32/hr) + (1 hr x $95.22/hr) + (1 hr x $48.16/hr) + (1 hr x $40.02/hr) + (0.083 hr x $95.22/hr)].
For the CY 2022 MIPS performance period/2024 MIPS payment year, in aggregate, we estimate a burden of 472,643 hours [9.08 hr/response x (40,507 clinicians submitting as individuals + 11,529 groups submitting via QCDR or MIPS CQM on behalf of individual clinicians or 52,036 responses)] at a cost of $48,016,739 (52,036 responses x $922.76/response) for the 2021 performance period. For the CY 2023 MIPS performance period/2025 MIPS payment year, in aggregate, we estimate a burden of 425,902 hours [9.083 hr/response x (36,456 clinicians submitting as individuals + 10,434 groups submitting via QCDR or MIPS CQM on behalf of individual clinicians or 46,890 responses)] at a cost of $43,268,216 (46,890 responses x $922.76/response). Based on these assumptions, we have estimated in Table 11 the burden for these submissions.
TABLE 11: Estimated Burden for Quality Performance Category:
Clinicians (Participating Individually or as Part of a Group)
Using the MIPS CQM and QCDR Collection Type
Burden and Respondent Descriptions |
2022 Performance Period Burden Estimate |
2023 Performance Period Burden Estimate |
# of clinicians submitting as individuals (a) |
40,507 |
36,456 |
# of groups submitting via QCDR or MIPS CQM on behalf of individual clinicians (b) |
11,529 |
10,434 |
# of Respondents (groups and clinicians submitting as individuals) (c)=(a)+(b) |
52,036 |
46,890
|
Hours Per Respondent to Report Quality Data (d) |
3 |
3 |
# of Hours Medical and health services manager Review Measure Specifications (e) |
2 |
2 |
# of Hours Computer Systems Analyst Review Measure Specifications (f) |
1 |
1 |
# of Hours LPN Review Measure Specifications (g) |
1 |
1 |
# of Hours Billing Clerk Review Measure Specifications (h) |
1 |
1 |
# of Hours Clinician Review Measure Specifications (i) |
1 |
1 |
# of Hours Per Respondent to Authorize Qualified Registry to Report on Respondent's Behalf (j) |
0.083 |
0.083 |
Annual Hours Per Respondent (k)= (d)+(e)+(f)+(g)+(h)+(i)+(j) |
9.083 |
9.083 |
Total Annual Hours (l) = (c)*(k) |
472,643 |
425,902 |
Cost Per Respondent to Submit Quality Data (@ computer systems analyst’s labor rate of $95.22/hr) (m) |
$285.66 |
$285.66 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $114.24/hr) (n) |
$228.48 |
$228.48 |
Cost Computer System’s Analyst Review Measure Specifications (@ computer systems analyst’s labor rate of $95.22/hr) (o) |
$95.22 |
$95.22 |
Cost LPN Review Measure Specifications (@ LPN's labor rate of $48.16/hr) (p) |
$48.16 |
$48.16 |
Cost Billing Clerk Review Measure Specifications (@ clerk’s labor rate of $40.02/hr) (q) |
$40.02 |
$40.02 |
Cost Physician Review Measure Specifications (@ physician’s labor rate of $217.32/hr) (r) |
$217.32 |
$217.32 |
Cost for Respondent to Authorize Qualified Registry/QCDR to Report on Respondent's Behalf (@ computer systems analyst’s labor rate of $95.22/hr) (s) |
$7.90 |
$7.90 |
*Total Annual Cost Per Respondent (t) = (m)+(n)+(o)+(p)+(q)+(r)+(s) |
$922.76 |
$922.76 |
*Total Annual Cost (u) = (c)*(t) |
$48,016,739* |
$43,268,216* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
In the CY 2022 PFS proposed rule, we propose to extend the CMS Web Interface as a collection type and submission type for the CY 2022 MIPS performance period/2024 MIPS payment year. In the CY 2022 PFS proposed rule, and we also propose to sunset the CMS Web Interface measures as a collection type and submission type starting with the CY 2023 MIPS performance period/2025 MIPS payment year. Using the methodology previously described, for the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate 66 groups which previously submitted quality data via the CMS Web Interface collection type will now submit quality data via the eCQM collection type.
As noted in Table 12 below, based on data in the CY 2019 MIPS performance period/2021 MIPS payment year, for the CY 2022 MIPS performance period/2024 MIPS payment year, we assume that 40,446 clinicians will submit eCQMs as individuals, and 8,127 groups and virtual groups will submit quality data using the eCQM collection type. For the CY 2023 MIPS performance period/2025 MIPS payment year, due to the proposed policy in the CY 2022 PFS proposed rule for implementation of voluntary MVP reporting, we assume that 36,401 clinicians will submit eCQMs as individuals, and 7,372 groups and virtual groups will submit quality data using the eCQM collection type. We expect the burden to be the same for each respondent using the eCQM collection type, whether the clinician is participating in MIPS as an individual or group.
Under the eCQM collection type, the individual clinician or group may either submit the quality measures data directly to us from their eCQM, log in and upload a file, or utilize a third-party intermediary to derive data from their CEHRT and submit it to us on the clinician’s or group’s behalf.
To prepare for the eCQM collection type, the clinician or group must review the quality measures on which we will be accepting MIPS data extracted from eCQMs, select the appropriate quality measures, extract the necessary clinical data from their CEHRT, and submit the necessary data to a QCDR/qualified registry or use a health IT vendor to submit the data on behalf of the clinician or group. We assume the burden for collecting quality measures data via eCQM is similar for clinicians and groups who submit their data directly to us from their CEHRT and clinicians and groups who use a health IT vendor to submit the data on their behalf. This includes extracting the necessary clinical data from their CEHRT and submitting the necessary data to the QCDR/qualified registry.
We estimate that it will take no more than 2 hours at $95.22/hr for a computer systems analyst to submit the actual data file. The burden will also involve becoming familiar with MIPS submission. In this regard, we estimate it will take 6 hours for a clinician or group to review measure specifications. Of that time, we estimate 2 hours at $114.24/hr for a medical and health services manager, 1 hour at $217.32/hr for a physician, 1 hour at $95.22/hr for a computer systems analyst, 1 hour at $48.16/hr for an LPN, and 1 hour at $40.02/hr for a billing clerk. As shown in Table 12, we estimate a cost of $819.64/response [(2 hr x $95.22/hr) + (2 hr x $114.24/hr) + (1 hr x $217.32/hr) + (1 hr x $95.22/hr) + (1 hr x $48.16/hr) + (1 hr x $40.02/hr)].
For the CY 2022 MIPS performance period/2024 MIPS payment year, in aggregate, we estimate a burden of 388,584 hours [8 hr x 48,573 (8,127 groups and 40,446 clinicians submitting as individuals)] at a cost of $39,812,374 (48,573 responses x $819.64/response). For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate a burden of 350,186 hours [8 hr x 43,773 (7,372 groups and 36,401 clinicians submitting as individuals)] at a cost of $35,878,102 (43,773 responses x $819.64/response).
TABLE 12: Estimated Burden for Quality Performance Category:
Clinicians
(Submitting Individually or as Part of a Group)
Using the eCQM Collection Type
Burden and Respondent Descriptions |
2022 Performance Period Burden estimate |
2023 Performance Period Burden estimate |
# of clinicians submitting as individuals (a) |
40,446 |
36,401 |
# of Groups submitting via EHR on behalf of individual clinicians (b) |
8,127 |
7,372 |
# of Respondents (groups and clinicians submitting as individuals) (c)=(a)+(b) |
48,573 |
43,773 |
Hours Per Respondent to Submit MIPS Quality Data File to CMS (d) |
2 |
2 |
# of Hours Medical and health services manager Review Measure Specifications (e) |
2 |
2 |
# of Hours Computer Systems Analyst Review Measure Specifications (f) |
1 |
1 |
# of Hours LPN Review Measure Specifications (g) |
1 |
1 |
# of Hours Billing Clerk Review Measure Specifications (h) |
1 |
1 |
# of Hours Clinicians Review Measure Specifications (i) |
1 |
1 |
Annual Hours Per Respondent (j)=(d)+(e)+(f)+(g)+(h)+(i) |
8 |
8 |
Total Annual Hours (k)=(c)*(j) |
388,584 |
350,184 |
Cost Per Respondent to Submit Quality Data (@ computer systems analyst’s labor rate of $95.22/hr) (l) |
$190.44 |
$190.44 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $114.24/hr) (m) |
$228.48 |
$228.48 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $95.22/hr) (n) |
$95.22 |
$95.22 |
Cost to Review Measure Specifications (@ LPN's labor rate of $48.16/hr) (o) |
$48.16 |
$48.16 |
Cost to Review Measure Specifications (@ clerk’s labor rate of $40.02/hr) (p) |
$40.02 |
$40.02 |
Cost to D21Review Measure Specifications (@ physician’s labor rate of $217.32/hr) (q) |
$217.32 |
$217.32 |
*Total Cost Per Respondent (r)=(l)+(m)+(n)+(o)+(p)+(q) |
$819.64 |
$819.64 |
*Total Annual Cost (s) = (c)*(r) |
$39,812,374 |
$35,878,102 |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
We propose to add a new set of ICRs to capture the burden associated with the proposed implementation of voluntary MIPS Value Pathways (MVP) reporting for eligible clinicians beginning with the CY 2023 MIPS performance period/2025 MIPS payment year as described in the CY 2022 PFS proposed rule (86 FR 39356 through 39358). If this proposal is finalized, clinicians participating in MIPS would have the option to voluntarily submit data using MVPs starting with the CY 2023 MIPS performance period/2025 MIPS payment year. We also propose that clinicians participating in MIPS through reporting MVPs could also choose to form subgroups beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. The MVPs would include the Promoting Interoperability performance category as a foundational element and incorporate population health claims-based measures, as feasible, along with the relevant measures and activities in the quality, cost and improvement activities performance categories. We estimate that the clinicians choosing to participate in MIPS for reporting MVPs would need to select from a reduced inventory of measures and activities for the quality and improvement activities performance categories. This reduction in burden is described in the quality, improvement activities and Promoting Interoperability performance categories sections below. The following new ICRs reflect the burden associated with the first year of data collection related to the proposed implementation of MVPs and subgroup reporting in the CY 2023 MIPS performance period/2025 MIPS payment year as described in the CY 2022 PFS proposed rule. For the ICRs related to MVP participants, we used the MIPS submission data from the CY 2019 MIPS performance period/2021 MIPS payment year. We assume that a total of 10 percent of MIPS submitters will become MVP participants in the CY 2023 MIPS performance period/2025 MIPS payment year.
Due to the limited number of MVPs available for clinicians to choose, the additional burden involved in reporting, and given the voluntary option to participate as subgroups for reporting the MVPs or the APP, we anticipate that a relatively small number of clinicians would choose to participate as subgroups in the CY 2023 MIPS performance period/2025 MIPS payment year. If the subgroup proposal is finalized, we assume there will be 20 subgroups reporters in the CY 2023 MIPS performance period/2025 MIPS payment year. We assume that more clinicians will choose to participate as subgroups in future years.
Beginning with the CY 2023 MIPS performance period/2025 MIPS payment year, we propose that clinicians interested in participating in MIPS through MVP reporting would be required to complete an annual registration process described in the CY 2022 PFS proposed rule (86 FR 39374 through 39376). At the time of registration, MVP participants would need to select a specific MVP, a population health measure and if administrative claims measures are included in the selected MVP, the MVP participants would also need to choose an applicable administrative claims measure in the MVP. In Table 13 below, we estimate that the registration process for clinicians choosing to submit MIPS data for the measures and the activities in an MVP would require 0.25 hours of a computer systems analyst’s time, similar to the currently approved burden of group registration process for CMS Web Interface finalized in the CY 2021 PFS final rule (85 FR 84983) for the CY 2023 MIPS performance period/2025 MIPS payment year. We assume that the staff involved in the MVP registration process will mainly be computer systems analysts or their equivalent, who have an average labor cost of $95.22/hour.
Based on data from the CY 2019 MIPS performance period/2021 MIPS payment year, we assume that approximately 10 percent of the clinicians that currently participate in MIPS will submit data for the measures and activities in an MVP. Note that we apply this 10 percent calculation after adding the clinicians who begin submitting though the CQM and eCQM collection types due to the proposed sunset of Web Interface in the CY 2023 MIPS performance period/2025 MIPS payment year. For the CY 2023 MIPS performance period/2025 MIPS payment year, we assume that a total of 25,798 submissions would be received for the measures and activities included in MVPs. This total includes our estimate of 20 subgroup reporters that will also be reporting MVPs in addition to MVP reporters who currently participate in MIPS. Therefore, we assume that the total number of individual clinicians, groups, subgroups and APM Entities to complete the MVP registration process is 12,918. We estimate that it would take 3,229 hours (12,917 registrants x 0.25 hr/registration) for clinicians participating as individuals and groups to complete the MVP registration process at a cost of $307,465 (3,229 hours x 95.22/hr). Table 13 includes our burden assumptions related to the MVP registration process for clinicians participating in MIPS for reporting MVPs as individuals, groups, subgroups, and APM Entities.
TABLE 13: Total Estimated Burden for MVP Registration (Individual clinicians, Groups, Subgroups and APM Entities)
Burden and Respondent Descriptions |
Burden Estimate |
Estimated # of Individual clinicians, groups, subgroups and APM Entities Registering (a) |
12,917 |
Estimated Total Annual Burden Hours Per Registration (b) |
0.25 |
Estimated Total Annual Burden Hours for MVP Registration (c) = (a) * (b) |
3,229 |
Estimated Cost Per MVP (@ computer systems analyst’s labor rate of $95.22/hr. (d) |
$95.22 |
Estimated Total Annual Burden Cost for MVP Registration (e) = (c) * (d) |
$307,465 |
We propose to add a separate ICR to estimate the burden associated with subgroup registration to capture the proposed subgroup registration requirements, as described in the CY 2022 PFS proposed rule. In the CY 2022 PFS proposed rule (86 FR 39360 through 39361), we also propose to define a subgroup at § 414.1305 as a subset of a group, as identified by a combination of the group TIN, the subgroup identifier, and each eligible clinician’s NPI. In addition to the burden for MVP registration process described above in Table 13, clinicians who choose to form subgroups for reporting the MVPs or the APP would need to submit a list of each TIN/NPI associated with the subgroup and a plain language name for the subgroup in a manner specified by CMS, as described in the CY 2022 PFS proposed rule. For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate that clinicians would choose to form 20 subgroups for reporting the measures and activities in MVPs. Additionally, we estimate that clinicians who choose to participate as subgroups for reporting MVPs would require a minimum of 0.5 hours per subgroup respondent to submit the proposed requirements for subgroup registration. As shown in Table 14 below, we assume that the staff involved in the subgroup registration process will mainly be computer systems analysts or their equivalent, who have an average labor cost of $95.22/hr. In aggregate, we estimate that it will take 10 hours (20 subgroups x 0.5 hr/subgroup) to complete the subgroup registration process at a cost of $952 (10 hours x 95.22/hr)
As all subgroups will report MVPs, the burden associated with subgroup quality reporting will be included with the MVP quality reporting ICR. Burden associated with subgroup submissions for Promoting Interoperability and improvement activities will be included with those ICRs.
TABLE 14: Total Estimated Burden for Subgroup Registration CY 2023 MIPS Performance Period/2025 MIPS payment year
Burden and Respondent Descriptions |
Burden Estimate |
Estimated # of Subgroups Registering(a) |
20 |
Estimated Total Annual Burden Hours Per Subgroup (b) |
0.5 |
Estimated Total Annual Burden Hours for Subgroup Reporting (c) = (a) * (b) |
10 |
Estimated Cost Per Subgroup (@ computer systems analyst’s labor rate of $95.22/hr. (d) |
$95.22 |
Estimated Total Annual Burden Cost for Subgroup Registration (e) = (a) * (d) |
$952 |
In the CY 2017 PFS final rule (81 FR 77100 through 77114), we established the submission criteria for quality measures (excluding the CMS Web Interface measures and the CAHPS for MIPS survey measure) at § 414.1335, which requires a MIPS eligible clinician, group, or virtual group that is reporting on Qualified Clinical Data Registry (QCDR) measures, MIPS clinical quality measures (MIPS CQMs), electronic CQMs (eCQMs), or Medicare Part B claims measures to submit data on at least six measures, including at least one outcome measure. As discussed in the CY 2022 PFS proposed rule (86 FR 39370 through 39371), we propose that except as provided in paragraph § 414.1365(c)(1)(i), an MVP Participant must select and report 4 quality measures, including 1 outcome measure (or, if an outcome measure is not available, 1 high priority measure, included in the MVP. The decrease in the number of required measures in the quality performance category from 6 to 4 is a two-thirds reduction in the number of measures needed for eligible clinicians to submit data for the quality performance category in MVPs described in Appendix 3: MVP Inventory of the CY 2022 PFS proposed rule. Therefore, we estimate that the time for submitting the measures in the MVP quality performance category will, on average, take two-thirds of the currently approved burden per respondent for the quality performance category as it does to complete a MIPS quality submission through the CQM, eCQM, and Claims submission types.
Based on our review of the proposed inventory of 7 MVPs in Appendix 3: MVP Inventory of the CY 2022 PFS proposed rule, and the existing submission trends in MIPS for the measures and activities included in these MVPs, we anticipate that 10 percent of the clinicians who participate in traditional MIPS in the CY 2022 MIPS performance period/2024 MIPS payment year will report MVPs in the CY 2023 MIPS performance period/2025 MIPS payment year. Given that MVPs are new, voluntary, and represent a reduction in burden per response, we believe that we should be conservative in estimating the number of clinicians submitting through MVPs during the initial year. Given that MVPs are a new mechanism available for clinicians, we believe that initial participation numbers will be relatively low. In an effort to be conservative in our estimate of burden reduction due to MVP reporting and reflect the anticipate low uptake by clinicians in the first year of MVP availability, we estimate that 10 percent of the clinicians who participated in MIPS for the CY 2019 MIPS performance period/2021 MIPS payment year, and 20 subgroups would submit data for the quality performance category of MVPs beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. As shown in Table 15, we estimate that approximately 2,825 clinicians would submit data for the MVP quality performance category using the Medicare Part B claims collection type; approximately 5,210 clinicians and 10 subgroups will submit data using MIPS CQM and QCDR collection type; and approximately 4,862 clinicians and 10 subgroups will submit data using eCQMs collection type. We want to note that we used the same methodologies used for information collection regarding quality data submission in CY 2021 PFS final rule (85 FR 84970 through 85 FR 84980) to estimate the quality submission burden for each collection type. As shown in Table 15, for the clinicians and subgroups submitting data for the MVP quality performance category, we estimate a burden of 26,688 hours (9.44 hr x 2,825 clinicians) at a cost of $2,691,329 (2,825 respondents x 952.68/respondent) for the Medicare Part B claims collection type, 31,163 hours [5.97 hr x 5,220 (5,210 +10)] at a cost of $3,211,216 (5,220 x 615.18/respondent) for the MIPS CQM and QCDR collection type, and 25,822 hours [5.3 hr x 4,872 (4,862 +10) respondents] at a cost of $2,662,191 (4,872 x 546.43/respondent) for the eCQM collection types.
TABLE 15: Estimated Burden for Quality Performance Category: Clinicians Submitting Data for MVPs in CY 2023
Burden and Respondent Descriptions |
eCQM Collection Type |
CQM and QCDR Collection Type |
Claims Collection Type |
# of Submissions from pre-existing collection types (a) |
4,862 |
5,210 |
2,825 |
# of Subgroup reporters (b) |
10 |
10 |
0 |
Total MVP participants (c) = (a) + (b) |
4,872 |
5,220 |
2,825 |
Hours Per Clinician to Submit Quality Data (d) |
1.33 |
2 |
4.8 |
# of Hours Medical and Health Services Manager Review Measure Specifications (e) |
1.33 |
1.33 |
2 |
# of Hours Computer Systems Analyst Review Measure Specifications (f) |
0.66 |
0.66 |
0.66 |
# of Hours LPN Review Measure Specifications (g) |
0.66 |
0.66 |
0.66 |
# of Hours Billing Clerk Review Measure Specifications (h) |
0.66 |
0.66 |
0.66 |
# of Hours Physician Review Measure Specifications (i) |
0.66 |
0.66 |
0.66 |
Annual Hours per Clinician Submitting Data for MVPs (j) = (d) + (e) + (f) + (g) + (h) + (i) |
5.3* |
5.97* |
9.44* |
Total Annual Hours (k) = (c) * (j) |
25,822* |
31,163* |
26,688* |
Cost to Submit Quality Data (@ computer systems analyst’s labor rate of $95.22/hr @ varying times) (k) |
$126.64 |
$190.44 |
$457.06 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $114.24/hr) (l) |
$151.94 |
$151.94 |
$228.48 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $95.22/hr) (m) |
$62.85 |
$62.85 |
$62.85 |
Cost to Review Measure Specifications (@ LPN's labor rate of $48.16/hr) (n) |
$31.79 |
$31.79 |
$31.79 |
Cost to Review Measure Specifications (@ billing clerk’s labor rate of $40.02/hr) (o) |
$26.41 |
$26.41 |
$26.41 |
Cost to Review Measure Specifications (@ physician’s labor rate of $217.32/hr) (p) |
$144.88 |
$144.88 |
$144.88 |
*Total Annual Cost Per Clinician (q) = (k) + (l) + (m) + (n) + (o) + (p) |
$546.43 |
$615.18 |
$952.68 |
*Total Annual Cost (r) = (c) * (q) |
$2,662,191 |
$3,211,216 |
$2,691,329 |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
In the CY 2021 PFS final rule, we finalized our policy to sunset the CMS Web Interface measures as a collection type/submission type starting with the CY 2022 MIPS performance period/2024 MIPS payment year. As a result of this provision, for the CY 2022 MIPS performance period/2024 MIPS payment year, we estimated a burden of zero due to our assumption that all Web Interface respondents will alternately utilize either the MIPS CQM and QCDR or eCQM collection types (85 FR 84981). In the CY 2022 PFS proposed rule, we are proposing to continue the CMS Web Interface measures as a collection type for the CY 2022 MIPS performance period/2024 MIPS payment year. Additionally, we are proposing to sunset the CMS Web Interface measures as a collection type for the CY 2023 MIPS performance period/2025 MIPS payment year (86 FR 39391 through 39392).
For the CY 2022 MIPS performance period/2024 MIPS payment year, we assume 114 groups will submit quality data via the CMS Web Interface based on the number of groups who completed 100 percent of reporting quality data via the Web Interface in the CY 2019 MIPS performance period/2021 MIPS payment year. This is an increase of 114 groups from the currently approved number of 0 groups due to receipt of more current data. We estimate 44,385 clinicians will submit as part of groups via this method, an increase of 874 from our currently approved estimate of 0 clinicians.
The proposed burden associated with the group submission requirements is the time and effort associated with submitting data on a sample of the organization’s beneficiaries that is prepopulated in the CMS Web Interface. Our proposed burden estimate for submission includes the time (61.67 hours) needed for each group to populate data fields in the Web Interface with information on approximately 248 eligible assigned Medicare beneficiaries and submit the data (we will partially pre-populate the CMS Web Interface with claims data from their Medicare Part A and B beneficiaries). The patient data either can be manually entered; uploaded into the CMS Web Interface via a standard file format, which can be populated by CEHRT; or submitted directly. Each group must provide data on 248 eligible assigned Medicare beneficiaries (or all eligible assigned Medicare beneficiaries if the pool of eligible assigned beneficiaries is less than 248) for each measure. In aggregate, we estimate a burden of 7,030 hours (114 groups x 61.67 hr) at a cost of $669,433 (114 groups x 61.67 hr x $95.22/hr) for the CY 2022 MIPS performance period/2024 MIPS payment year. For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate a burden of zero due to our assumption that all Web Interface respondents will alternately utilize either the MIPS CQM and QCDR or eCQM collection types.
Based on the assumptions discussed in this section, Table 16 summarizes the burden for groups submitting to MIPS via the CMS Web Interface.
TABLE 16: Estimated Burden for Quality Data Submission via the CMS Web Interface
Burden and Respondent Descriptions |
2022 Performance Period Burden Estimate |
2023 Performance Period Burden Estimate |
# of Eligible Group Practices (a) |
114 |
0 |
Total Annual Hours Per Group to Submit (b) |
61.67 |
0 |
Total Annual Hours (c) = (a)*(b) |
7,030 |
0 |
Cost Per Group to Report (@ computer systems analyst’s labor rate of $95.22/hr.) (d) |
$5,872.21 |
$0 |
Total Annual Cost (e) = (a)*(d) |
$669,433 |
$0 |
Groups interested in participating in MIPS using the CMS Web Interface for the first time must complete an on-line registration process. After first time registration, groups will only need to opt out if they are not going to continue to submit via the CMS Web Interface. In Table 17, we estimate that the registration process for groups under MIPS involves approximately 0.25 hours at $90.02/hr for a computer systems analyst (or their equivalent) to register the group.
Because we propose to sunset the CMS Web Interface beginning with the CY 2023 MIPS performance period, it is possible that fewer groups will elect to register to submit quality data for the first time in the performance year prior to the collection type/submission type no longer being available; however, we currently have no data with which to estimate what the associated reduction may be. Therefore, we continue to assume that approximately 90 groups will elect to use the CMS Web Interface for the first time during the CY 2022 MIPS performance period/2024 MIPS payment year based on the number of new registrations received during the CY 2021 CMS Web Interface registration period. As shown in Table 17, we estimate a burden of 23 hours (90 new registrations x 0.25 hr/registration) at a cost of $2,190 (23 hr x $95.22/hr).
TABLE 17: Estimated Burden for Group Registration for CMS Web Interface
Burden and Respondent Descriptions |
2022 Performance Period Burden Estimate |
2023 Performance Period Burden Estimate |
Number of New Groups Registering for CMS Web Interface (a) |
90 |
0 |
Annual Hours Per Group (b) |
0.25 |
0 |
Total Annual Hours (c) = (a)*(b) |
23 |
0 |
Labor Rate to Register for CMS Web Interface @ computer systems analyst’s labor rate of $95.22/hr) (d) |
$95.22/hr |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
+$2,190 |
$0 |
Quality measures are
selected annually through a call for quality measures under
consideration, with a final list of quality measures being published
in the Federal Register by November 1 of each year. As described in
the CY 2017 Quality Payment Program final rule (81 FR 77137), we will
accept quality measures submissions at any time, but only measures
submitted during the timeframe provided by us through the
pre-rulemaking process of each year will be considered for inclusion
in the annual list of MIPS quality measures for the performance
period beginning two years after the measure is submitted. This
process is consistent with the pre-rulemaking process and the annual
call for measures, which are further described at
https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rule-Making.html.
Beginning with the 2021 Annual Call for Measures, we replaced the customary Office of the National Coordinator (ONC) Issue Tracking System Jira platform that stakeholders used to submit candidate quality measure specifications and all supporting data files for CMS review with the MUC Entry/Review Information Tool (MERIT). To identify and submit a quality measure, eligible clinician organizations and other relevant stakeholders use an online form that requests information on background, a gap analysis which includes evidence for the measure, reliability, validity, endorsement, and a summary which includes how the proposed measure relates to the Quality Payment Program and the rationale for the measure. MIPS quality measures are also required to be linked to existing and related cost measures and improvement activities, as applicable and feasible, with a rationale as to how the measure correlates to other performance category measures and activities. In addition, proposed measures must be accompanied by a completed Peer Review Journal Article form. For the ONC Issue Tracking System Jira platform used by stakeholders, the approved estimated time for a practice administrator to identify, propose, and link to a quality measure is 0.9 hours and for a clinician to identify, propose, link to quality measure, and complete the Peer Review Journal Article form is 4.6 hours (0.6 hours to identify, propose, and link to quality measure (84 FR 63132) and 4 hours to complete the Peer Review Journal Article Form (84 FR 63133), with a total estimated time of 5.5 hours per quality measure submission.
As shown in Table 18, we are not making any changes to our currently approved estimate of 28 quality measure submissions. Based on the stakeholder experience with the updated tool and additional information collected at the time of submission, we estimate that it would add approximately 1.5 hours for the practice administrator at $114.24/hr and 0.5 hours at $217.32/hr for a clinician to identify, propose, and link the quality measure, and reduce approximately 2 hours at $217.32/hr for a clinician to complete the Peer Review Journal Article Form, resulting in a new estimated time of 2.4 hours for a practice administrator and 3.1 hours for a clinician, and an unchanged total estimated time of 5.5 hours per quality measure submission.
As shown in Table 18, in aggregate we estimate an annual burden of 154 hours (28 submissions x 5.5 hr/submission) at a cost of $26,541 {28 submissions x [(2.4 hr x $114.24/hr) + (3.1 hr x $217.32/hr)]}.
TABLE 18: Burden Estimates for Call for Quality Measures
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations Nominating New Quality Measures (a) |
28 |
# of Hours Per Medical and health services manager to Identify and Propose Measure (b) |
2.4 |
# of Hours Per Clinician to Identify Measure (c) |
1.1 |
# of Hours Per Clinician to Complete Peer Review Article Form (d) |
2.00 |
Annual Hours Per Response (e)= (b) + (c) + (d) |
5.50 |
Total Annual Hours (f) = (a)*(e) |
154 |
Cost to Identify and Submit Measure (@practice administrator's labor rate of $114.24/hr.) * 2.4 hr (g) |
$274.20 |
Cost to Identify Quality Measure and Complete Peer Review Article Form (@ physician’s labor rate of $217.32/hr.) * 3.1 hr (h) |
$673.69 |
Total Annual Cost Per Respondent (i)=(g)+(h) |
$947.89 |
Total Annual Cost (j)=(a)*(i) |
$26,541* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
For the CY 2022 MIPS performance period/2024 MIPS payment year, clinicians and groups can submit Promoting Interoperability data through direct, log in and upload, or log in and attest submission types. With the exception of submitters who elect to use the log in and attest submission type for the Promoting Interoperability performance category, which is not available for the quality performance category, we anticipate that individuals and groups will use the same data submission type for the both of these performance categories and that the clinicians, practice managers, and computer systems analysts involved in supporting the quality data submission will also support the Promoting Interoperability data submission process. The following burden estimates show only incremental hours required above and beyond the time already accounted for in the quality data submission process. Although this analysis assesses burden by performance category and submission type, we emphasize MIPS is a consolidated program and submission analysis, and decisions are expected to be made for the program.
As established in the CY 2017 and CY 2018 Quality Payment Program final rules, MIPS eligible clinicians who meet the criteria for a significant hardship or other type of exception may submit an application requesting a zero percent weighting for the Promoting Interoperability, quality, cost, and/or improvement activities performance categories under specific circumstances (81 FR 77240 through 77243, 82 FR 53680 through 53686, and 82 FR 53783 through 53785). Respondents who apply for a reweighting for the quality, cost, and/or improvement activities performance categories have the option of applying for reweighting for the Promoting Interoperability performance category on the same online form. We assume respondents applying for a reweighting of the Promoting Interoperability performance category due to extreme and uncontrollable circumstances will also request a reweighting of at least one of the other performance categories simultaneously and not submit multiple reweighting applications.
Table 19 summarizes the burden for clinicians to apply for reweighting the Promoting Interoperability performance category to zero percent due to a significant hardship exception (including a significant hardship exception for small practices) or because of a decertification of an EHR. Based on the number of reweighting applications received by March 31, 2021 for the CY 2020 MIPS performance period/2022 MIPS payment year, we assume 20,192 respondents (eligible clinicians or groups) will submit a request to reweight the Promoting Interoperability performance category to zero percent due to a significant hardship (including clinicians in small practices) or EHR decertification and an additional 22,635 respondents will submit a request to reweight one or more of the quality, cost, Promoting Interoperability, or improvement activity performance categories due to an extreme or uncontrollable circumstance, for a total of 42,797 reweighting applications submitted. This is an increase of 9,302 respondents compared to our currently approved estimate of 52,099 respondents (85 FR 84984). Similar to the data used to estimate the number of respondents in the CY 2021 PFS final rule, our respondent estimate includes a significant number of applications submitted as a result of a data issue CMS was made aware of and is specific to a single third-party intermediary. While we do not anticipate similar data issues to occur in each performance period, we do believe future similar incidents may occur and are electing to use this data without adjustment to reflect this belief. Of our total respondent estimate of 42,797, we estimate that 22,605 respondents (eligible clinicians or groups) will submit a request for reweighting the Promoting Interoperability performance category to zero percent due to extreme and uncontrollable circumstances, insufficient internet connectivity, lack of control over the availability of CEHRT, or because of a decertification of an EHR.
We previously established under § 414.1380(c)(2)(i)(C)(9) a significant hardship exception for MIPS eligible clinicians in small practices as defined in § 414.1305. In the CY 2018 Quality Payment Program final rule (82 FR 53682 through 53683), we established we would reweight the Promoting Interoperability performance category to zero percent of the MIPS final score for MIPS eligible clinicians who qualify for this hardship exception. We established a MIPS eligible clinician seeking to qualify for this exception must submit an application to us demonstrating there are overwhelming barriers that prevent them from complying with the requirements for the Promoting Interoperability performance category, and the exception is subject to annual renewal. In the CY 2022 PFS proposed rule, we are proposing to no longer require an application for clinicians and small practices seeking to qualify for the small practice hardship exception and reweighting. We are proposing instead to assign a weight of zero percent to the Promoting Interoperability performance category for clinicians in small practices and redistribute its weight to another performance category or categories in the event no data is submitted for any of the measures for the Promoting Interoperability performance category by or on behalf of a MIPS eligible clinician in a small practice. Therefore, we estimate zero respondents will submit a request for reweighting the Promoting Interoperability performance category to zero percent as a small practice experiencing a significant hardship.
In the CY 2021 PFS final rule (85 FR 84984), we finalized that, beginning with the CY 2020 MIPS performance period/2022 MIPS payment year, APM Entities may submit an extreme and uncontrollable circumstances exception application for all four performance categories and applicable to all MIPS eligible clinicians in the APM Entity group. As previously discussed, due to data limitations and our inability to predict who would use the APM Performance Pathway versus the traditional MIPS submission mechanism for the CY 2022 MIPS performance period/2024 MIPS payment year, we assume ACO APM Entities will submit data through the APM Performance Pathway and non-ACO APM Entities would participate through traditional MIPS, thereby submitting as an individual or group rather than as an entity. Therefore, we limited our analysis to ACOs that were eligible for an exception due to extreme and uncontrollable circumstances during the CY 2020 MIPS performance period/2022 MIPS payment year and elected not to report quality data. Based on this data, we estimate that 30 APM Entities will submit an extreme and uncontrollable circumstances exception application for the CY 2022 MIPS performance period/2024 MIPS payment year. Combined with our estimate of 42,797 eligible clinicians and groups, the total estimated number of respondents for the CY 2022 MIPS performance period/2024 MIPS payment year is 42,827.
The application to request a reweighting to zero percent only for the Promoting Interoperability performance category is a short online form that requires identifying the type of hardship experienced or whether decertification of an EHR has occurred and a description of how the circumstances impair the clinician or group’s ability to submit Promoting Interoperability data, as well as some proof of circumstances beyond the clinician’s control. The application for reweighting of the quality, cost, Promoting Interoperability, and/or improvement activities performance categories due to extreme and uncontrollable circumstances requires the same information apart from there being only one option for the type of hardship experienced. We continue to estimate it will take 0.25 hours at $95.22/hr for a computer system analyst to complete and submit the application. As shown in Table 19, we estimate an annual burden of 10,707 hours (42,827 applications x 0.25 hr/application) at an annual cost of $1,019,521 (42,827 applications x 0.25 hr x $95.22/hr).
TABLE 19: Estimated Burden for Reweighting Applications for Promoting Interoperability and Other Performance Categories
Burden and Respondent Descriptions |
Burden Estimate |
# of Eligible Clinicians and Groups Applying Due to Significant Hardship and Other Exceptions (a) |
42,797 |
# of Eligible Clinicians and Groups Applying Due to Significant Hardship for Small Practice (b) |
0 |
# APM Entities requesting Extreme and Uncontrollable Circumstances exception (c) |
30 |
Total Respondents Due to Hardships, Other Exceptions and Hardships for Small Practices (d) = (a) + (b) + (c) |
42,827 |
Hours Per Applicant per application submission (e) |
0.25 |
Total Annual Hours (f)=(e)*(d) |
10,707 |
Labor Rate for a computer systems analyst (g) |
$95.22/hr |
Total Annual Cost (h)=(g)*(f) |
$1,019,521* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
A variety of organizations will submit Promoting Interoperability data on behalf of clinicians. Clinicians not participating in a MIPS APM may submit data as individuals or as part of a group. In the CY 2017 Quality Payment Program final rule (81 FR 77258 through 77260, 77262 through 77264) and CY 2019 PFS final rule (83 FR 59822-59823), we established that eligible clinicians in MIPS APMs (including the Shared Savings Program) may report for the Promoting Interoperability performance category as an APM Entity group, individuals, or a group.
As shown in Table 20, based on data from the CY 2019 MIPS performance period/2021 MIPS payment year, we estimate that a total of 51,647 respondents consisting of 40,172 individual MIPS eligible clinicians and 11,475 groups and virtual groups will submit Promoting Interoperability data, a decrease of 1,989 respondents from the currently approved estimate of 53,636.
Certain MIPS eligible clinicians will be eligible for automatic reweighting of the Promoting Interoperability performance category to zero percent, including MIPS eligible clinicians who are hospital-based, ambulatory surgical center-based, non-patient facing clinicians, physician assistants, nurse practitioners, clinician nurse specialists, certified registered nurse anesthetists, physical therapists; occupational therapists; qualified speech-language pathologists or qualified audiologist; clinical psychologists; and registered dieticians or nutrition professionals. In the CY 2022 PFS proposed rule (86 FR 39426), we propose to apply the automatic reweighting of the Promoting Interoperability performance category to clinical social workers. These estimates also account for the proposed automatic reweighting policies for clinicians who are in small practices, as described in the CY 2022 PFS proposed rule. These estimates account for previously finalized reweighting policies including exceptions for MIPS eligible clinicians who have experienced a significant hardship and decertification of an EHR.
Each MIPS eligible clinician in an APM Entity reports data for the Promoting Interoperability performance category through either their group TIN or individual reporting. Sections 1899 of the Act (42 U.S.C. 1395jjj) state that the Shared Savings Program and the testing, evaluation, and expansion of Innovation Center models are not subject to the PRA. However, in the CY 2019 PFS final rule, we established that MIPS eligible clinicians who participate in the Shared Savings Program are no longer limited to reporting for the Promoting Interoperability performance category through their ACO participant TIN (83 FR 59822 through 59823). Burden estimates for this proposed rule assume group TIN-level reporting as we believe this is the most reasonable assumption for the Shared Savings Program, which requires that ACOs include full TINs as ACO participants. As we receive updated information which reflects the actual number of Promoting Interoperability data submissions submitted by Shared Savings Program ACO participants, we will update our burden estimates accordingly.
TABLE 20: Estimated Number of Respondents to Submit Promoting Interoperability Performance Data on Behalf of Clinicians
Respondent Descriptions |
# of Respondents |
Number of individual clinicians to submit Promoting Interoperability (a) |
40,172 |
Number of groups to submit Promoting Interoperability (b) |
11,475 |
Total Respondents in CY 2022 MIPS performance period (CY 2022 Proposed Rule) (c) = (a) + (b) |
51,647 |
Total Respondents in CY 2021 MIPS performance period (CY 2021 Final Rule) (d) |
53,636 |
Difference (e) = (c) – (d) |
-1,989 |
In the CY 2022 PFS proposed rule (86 FR 39415 through 39416), we propose the additional requirement that eligible clinicians must attest to conducting an annual assessment of the High Priority Guides of the SAFER Guides beginning January 1, 2022. Clinicians will complete this attestation by checking a box when they submit their promoting interoperability performance category data. We estimate that this requirement will add an additional minute (+0.02 hr) to the currently approved estimated time (2.67 hr) it takes to complete the submission of Promoting Interoperability data. Therefore, we estimate the time required for an individual or group to submit Promoting Interoperability data to be 2.69 hours (2.67 hr + 0.02 hr). As shown in Table 21, the total burden estimate for submitting data on the specified Promoting Interoperability objectives and measures is estimated to be 138,930 hours (51,647 respondents x 2.69 incremental hours for a computer analyst’s time above and beyond the physician, medical and health services manager, and computer system’s analyst time required to submit quality data) and $13,228,915 (138,586 hr x $95.22/hr)).
TABLE 21: Estimated Burden for Promoting Interoperability
Performance Category
Data Submission in CY 2022
Burden and Respondent Descriptions |
Burden Estimate |
Number of individual clinicians to submit Promoting Interoperability (a) |
40,172 |
Number of groups to submit Promoting Interoperability (b) |
11,475 |
Total (c) = (a) + (b) |
51,647 |
Total Annual Hours Per Respondent (d) |
2.69 |
Total Annual Hours (e) = (c)*(d) |
138,930* |
Labor rate for a computer systems analyst to submit Promoting Interoperability data/hr. (f) |
$95.22/hr |
Total Annual Cost (g) = (e)*(f) |
$13,228,915* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
In the CY 2022 PFS proposed rule (86 FR 39357 through 39358), we propose voluntary subgroup reporting for eligible clinicians beginning with the CY 2023 MIPS performance period/2025 MIPS payment year. The subgroup reporting option is available for only those clinicians that would participate in MIPS through reporting of the measures and activities in an MVP or APP. For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate that 20 subgroups will submit data for the Promoting Interoperability performance category within MVPs. In aggregate, for the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate that the total proposed burden estimate for submitting data on the specified Promoting Interoperability objectives and measures is estimated to be 138,984 hours (51,667 respondents x 2.69 incremental hours for a computer analyst’s time above and beyond the physician, medical and health services manager, and computer system’s analyst time required to submit quality data) and $13,234,078 (138,640 hr x $95.22/hr).
TABLE
22: Estimated Burden for Promoting Interoperability Performance
Category
Data Submission in CY 2023
Burden and Respondent Descriptions |
Burden Estimate |
Number of individual clinicians to submit Promoting Interoperability (a) |
40,172 |
Number of groups to submit Promoting Interoperability (b) |
11,475 |
Number of subgroups to submit Promoting Interoperability (c) |
20 |
Total (d) = (a) + (b) + (c) |
51,667 |
Total Annual Hours Per Respondent (e) |
2.69 |
Total Annual Hours (f) = (d) * (e) |
138,984* |
Labor rate for a computer systems analyst to submit Promoting Interoperability data (g) |
$95.22/hr |
Total Annual Cost (h) = (f) * (g) |
$13,234,078* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
Promoting Interoperability measures may be submitted via the Call for Promoting Interoperability Performance Category Measures Submission Form that includes the measure description, measure type (if applicable), reporting requirement, and CEHRT functionality used (if applicable). We are not finalizing any changes to that form.
Unchanged from our currently approved estimate, we estimate 10 proposals will be submitted for new Promoting Interoperability measures, based on the number of proposals submitted during the CY 2020 nomination period. We estimate it will take 0.5 hours per organization to submit an activity to us, consisting of 0.3 hours at $114.24/hr for a medical and health services manager to make a strategic decision to nominate that activity and submit an activity to us via email and 0.2 hours at $217.32/hr for a clinician to review the nomination. As shown in Table 23, we estimate an annual burden of 5 hours (10 proposals x 0.5 hr/response) at a cost of $777 (10 x [(0.3 h x $114.24/hr) + (0.2 hr x $217.32/hr)].
TABLE 23: Estimated Burden for Call for Promoting Interoperability Measures
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations Nominating New Promoting Interoperability Measures (a) |
10 |
# of Hours Per Medical and health services manager to Identify and Propose Measure (b) |
0.30 |
# of Hours Per Clinician to Identify Measure (c) |
0.20 |
Annual Hours Per Respondent (d)= (b) + (c) |
0.50 |
Total Annual Hours (e) = (a)*(d) |
5 |
Cost to Identify and Submit Measure (@ medical and health services manager's labor rate of $114.24/hr.) (f) |
$34.27 |
Cost to Identify Improvement Measure (@ physician’s labor rate of $217.32/hr.) (g) |
$43.46 |
Total Annual Cost Per Respondent (h)=(f)+(g) |
$77.73 |
Total Annual Cost (i)=(a)*(h) |
$777 |
In order to determine MIPS APM scores, we assign improvement activities scores to APM participants in the APP based on the requirements of participation in APMs. To develop the improvement activities score for MIPS APMs, we would compare requirements of the APM with the list of improvement activities measures for the applicable year and score those measures as they would otherwise be scored according to § 414.1355. In the event a MIPS APM participant does not actually perform an activity for which improvement activities credit would otherwise be assigned under this provision, the MIPS APM participant would not receive credit for the associated improvement activity. In the event that the assigned score does not represent the maximum improvement activities score, we specify that MIPS eligible clinicians reporting through the APP would have the opportunity to report additional improvement activities that then would be applied towards their scores. Our burden estimates assume there will be no improvement activities burden for MIPS APM participants electing the APP. We will assign the improvement activities performance category score at the APM Entity level.
A variety of organizations and in some cases, individual clinicians, will submit improvement activity performance category data. As finalized in the CY 2017 Quality Payment Program final rule (81 FR 77264), APM Entities only need to report improvement activities data if the CMS-assigned improvement activities score is below the maximum improvement activities score. Similar to our assumption in the CY 2018 Quality Payment Program final rule, our burden estimates assume that all MIPS APM models for the CY 2022 MIPS performance period/2024 MIPS payment year will qualify for the maximum improvement activities performance category score and, as such, APM Entities will not submit any additional improvement activities. (82 FR 53921 through 53922).
As represented in Table 24, based on CY 2019 MIPS performance period/2021 MIPS payment year data, we estimate that a total of 81,562 respondents consisting of 63,845 individual clinicians and 17,717 groups will submit improvement activities during the CY 2022 MIPS performance period/2024 MIPS payment year, an increase of +1,635 respondents from our currently approved estimate of 79,927. In addition, regarding our estimate of clinicians and groups submitting data for the quality and Promoting Interoperability performance categories, we have updated our estimates for the number of clinicians and groups that will submit improvement activities data based on projections of the number of eligible clinicians that were not QPs or members of an ACO in the CY 2019 MIPS performance period/2021 MIPS payment year, but will be in the CY 2022 MIPS performance period/2024 MIPS payment year, and will therefore not be required to submit improvement activities data.
TABLE 24: Estimated Numbers of Organizations Submitting Improvement Activities Performance Category Data on Behalf of Clinicians
Respondent Descriptions |
Count |
# of clinicians to participate in improvement activities data submission as individuals during the CY 2022 MIPS performance period (a) |
63,845 |
# of Groups to submit improvement activities on behalf of clinicians during the 2022 MIPS performance period (b) |
17,717 |
Total # of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of clinicians during the CY 2022 MIPS performance period (CY 2022 Proposed Rule) (c) = (a) + (b) |
81,562 |
*Total # of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of clinicians during the CY 2019 MIPS performance period (CY 2021 Final Rule) (d) |
79,927 |
Difference (e)=(c)-(d) |
Consistent with our currently approved estimate, we estimate that the per response time required per individual or group is 5 minutes at $95.22/hr for a computer system analyst to submit by logging in and manually attesting that certain activities were performed in the form and manner specified by CMS with a set of authenticated credentials (83 FR 60016).
As shown in Table 25, we estimate an annual burden of 6,797 hours (81,562 responses x 5 minutes/60) and $647,210 (6,797 hr x $95.22/hr).
TABLE 25: Estimated Burden for Improvement Activities Submission in CY 2022
Burden and Respondent Descriptions |
Burden Estimate |
Total # of Respondents (Groups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of clinicians during the CY 2022 MIPS performance period (a) |
81,562 |
Total Annual Hours Per Respondent (b) |
0.083 |
Total Annual Hours (c) |
6,797 |
Labor rate for a computer systems analyst to submit improvement activities (d) |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
In the CY 2022 PFS proposed rule (86 FR 39357 through 39358), we are proposing subgroup reporting in the CY 2023 MIPS performance period/2025 MIPS payment year. We estimate that there will be 20 subgroup reporters in the CY 2023 MIPS performance period/2025 MIPS payment year, each of which will have burden related to the submission of improvement activities. For the CY 2023 MIPS performance period/2025 MIPS payment year, we estimate an annual burden of 6,771 hours (81,582 responses x 0.083) and $644,735 (6,771 hr x $95.22/hr).
TABLE 26: Estimated Burden for Improvement Activities Submission in CY 2023
Burden and Respondent Descriptions |
Burden Estimate |
Total # of Respondents (Groups, Subgroups, Virtual Groups, and Individual Clinicians) to submit improvement activities data on behalf of clinicians during the CY 2023 MIPS performance period (a) |
81,582 |
Total Annual Hours Per Respondent (b) |
0.083 |
Total Annual Hours (c) |
6,771 |
Labor rate for a computer systems analyst to submit improvement activities (d) |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
$644,735* |
*Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
Stakeholders are provided an opportunity to propose new activities formally via the Annual Call for Activities nomination form posted on the CMS website. Due to the PHE for COVID-19, we continue to use our currently approved assumption that we will receive 31 nominations of new or modified activities which will be evaluated for the Improvement Activities Under Consideration (IAUC) list for possible inclusion in the CY 2022 Improvement Activities Inventory as we believe this estimate is more realistic than basing our estimate on the number of nominations received during the 2020 Annual Call for Activities
In the CY 2022 PFS proposed rule, we are proposing 2 new criteria that beginning with the CY 2022 Annual Call for Activities MIPS improvement activities: (1) should not duplicate other improvement activities in the Inventory; and (2) should drive improvements that go beyond purely common clinical practices. Additionally, we are proposing to increase the number of criteria stakeholders are required to meet when submitting an activity proposal from a minimum of 1 to all 8 criteria, which includes the two new proposed criteria (86 FR 39406 through 39408). We believe that this proposal would provide clearer guidance to stakeholders when submitting a nomination for an improvement activity. In the CY 2021 PFS final rule, we estimated that it would require 0.6 hours for a medical and health services manager or equivalent and 0.4 hours for a physician to link the nominated improvement activity to existing and related cost and quality measures (85 FR 84989). Given that our current approved estimated time per respondent to nominate an improvement activity is 3 hours (1.8 hours for a medical and health services manager or equivalent and 1.2 hours for a physician), we assume that the proposed new requirement to meet all 8 criteria would require approximately 1 hour at $114.24/hr for a medical and health services manager to identify and submit an activity and 0.4 hours at a rate of $217.32/hr for a clinician to review each activity. Combined with our currently approved burden estimate, we propose to revise our estimate to 2.8 hours at $114.24/hr for a medical and health services manager or equivalent and 1.6 hours at $217.32 /hr for a physician to nominate an improvement activity. This represents a change of +1 hours (2.8 hr - 1.8 hr) for a medical and health services manager or equivalent and +0.4 hours (2 hr -1.6 hr) for a physician and an overall increase of 1.4 hours. We considered whether we should double our estimates for nomination of an improvement activity to 6 hours. Since only 2 of the required 8 criteria are new, we assume that stakeholders are familiar with the existing criteria and would not need additional time to review but would need the additional time to verify and confirm if the considered activity meets all the 8 criteria. We continue to use our currently approved assumption that we will receive 31 nominations of new or modified activities which will be evaluated for the Improvement Activities Under Consideration (IAUC) list for possible inclusion in the CY 2023 Improvement Activities Inventory. Therefore, we estimate an annual information collection burden of 136 hours (31 nominations x 4.4 hr/nomination) at a cost of $20,695 (31 x [(2.8 hr x $114.24/hr) + (1.6 hr x $217.32/hr)]).
TABLE 27: Burden Estimates for Nomination of Improvement Activities
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations Nominating New Improvement Activities (a) |
31 |
# of Hours Per Medical and health services manager to Identify and Propose Activity (b) |
2.8 |
# of Hours Per Clinician to Identify Activity (c) |
1.6 |
Annual Hours Per Respondent (d)= (b) + (c) |
4.4 |
Total Annual Hours (e) = (a)*(d) |
136 |
Cost to Identify and Submit Activity (@ medical and health services manager's labor rate of $114.24/hr.) (f) |
$319.87 |
Cost to Identify Improvement Activity (@ physician’s labor rate of $217.32/hr.) (g) |
$347.71 |
Total Annual Cost Per Respondent (h)=(f)+(g) |
$667.58 |
Total Annual Cost (i)=(a)*(h) |
$20,695 |
Beginning in CY 2021 for purposes of the CY 2022 policymaking, we stated stakeholders should formally submit their MVP candidates utilizing a standardized template, which will be published in the QPP resource library for our consideration for future implementation. Stakeholders should submit all information including a description of how their MVP abides by the MVP development criteria as described in the CY 2021 PFS final rule (85 FR 84849 through 84859), and provide rationales as to why specific measures and activities were chosen to construct the MVP. As MVP candidates are received, they will be reviewed, vetted, and evaluated by CMS and our contractors to determine if the MVP is feasible and ready for inclusion in the upcoming performance period. For the CY 2022 MIPS performance period/2024 MIPS payment year, we assume 25 MVP nominations will be received and the estimated time required to submit all required information is 12 hours per nomination.
Similar to the call for quality measures, nomination of Promoting Interoperability measures, and the nomination of improvement activities, we assume MVP nomination will be performed by both practice administration staff or their equivalents and clinicians. We estimate 7.2 hours at $114.24/hr for a medical and health services manager or equivalent and 4.8 hours at $217.32/hr for a physician to nominate an MVP. As shown in Table 28, we estimate an annual burden of 300 hours (25 nominations x 12 hr/nomination) at a cost of $46,642 (25 x [(7.2 hr x $114.24/hr) + (4.8 hr x $217.32/hr)]).
TABLE 28: Estimated Burden for Nomination of MVPs
Burden and Respondent Descriptions |
Burden Estimate |
# of Nominations of New Improvement Activities (a) |
25 |
# of Hours Per Medical and Health Services Manager (b) |
7.2 |
# of Hours Per Physician (c) |
4.8 |
Annual Hours Per Respondent (d)= (b) + (c) |
12 |
Total Annual Hours (e) = (a)*(d) |
300 |
Cost to Nominate an MVP (@ medical and health services manager's labor rate of $114.24/hr) (f) |
$822.53 |
Cost to Nominate an MVP (@ physician’s labor rate of $217.32/hr) (g) |
$1,043.14 |
Total Annual Cost Per Respondent (h)=(f)+(g) |
$1,865.67 |
Total Annual Cost (i)=(a)*(h) |
$46,642 |
The cost performance category relies on administrative claims data. The Medicare Parts A and B claims submission process (OMB control number 0938-1197; CMS-1500 and CMS-1490S) is used to collect data on cost measures from MIPS eligible clinicians. MIPS eligible clinicians are not required to provide any documentation by CD or hardcopy, including for the 10 episode-based measures we included in the cost performance category as discussed in the CY 2020 PFS final rule (84 FR 62959). Moreover, the policies of the CY 2022 proposed rule do not result in the need to add or revise or delete any claims data fields. Therefore, we did not propose any new or revised collection of information requirements or burden for MIPS eligible clinicians resulting from the cost performance category.
APM Entities may face a data submission burden under MIPS if they attain Partial QP status and elect to participate in MIPS. Advanced APM participants will be notified about their QP or Partial QP status as soon as possible after each QP determination. Where Partial QP status is earned at the APM Entity level, the burden of Partial QP election will be incurred by a representative of the participating APM Entity. Where Partial QP status is earned at the eligible clinician level, the burden of Partial QP election will be incurred by the eligible clinician. For the purposes of this burden estimate, we assume that all MIPS eligible clinicians determined to be Partial QPs will participate in MIPS.
As shown in Table 29, based on historical response rates in the CY 2020 MIPS performance period/2022 MIPS payment year, we estimate that 150 APM Entities and 100 eligible clinicians (representing approximately 9,000 Partial QPs) will make the election to participate as a Partial QP in MIPS, a total of 250 elections which is a decrease of 50 from the 300 elections that are currently approved by OMB under the aforementioned control number. We continue to estimate it will take the APM Entity representative or eligible clinician 15 minutes (0.25 hr) to make this election. In aggregate, we estimate an annual burden of 63 hours (250 respondents x 0.25 hr/election) and $5,999 (63 hr x $95.22/hr).
TABLE 29: Estimated Burden for Partial QP Election
Burden and Respondent Descriptions |
Burden Estimate |
# of respondents making Partial QP election (150 APM Entities, 100 eligible clinicians) (a) |
250 |
Total Hours Per Respondent to Elect to Participate as Partial QP (b) |
0.25 |
Total Annual Hours (c) = (a)*(b) |
63 |
Labor rate for computer systems analyst (d) |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
$5,999 |
As previously discussed in the “Data Collection related to Advanced APMs” section, the All-Payer Combination Option is an available pathway to QP status for eligible clinicians participating sufficiently in Advanced APMs and Other Payer Advanced APMs. Payers seeking to submit payment arrangement information for Other Payer Advanced APM determination through the payer-initiated process are required to complete a Payer Initiated Submission Form, instructions for which is available at https://qpp.cms.gov/.
As shown in Table 30, based on the actual number of requests received for in the 2020 QP performance period, we propose to revise our estimate that in CY 2022 for the 2023 QP performance period, 15 payer-initiated requests for Other Payer Advanced APM determinations will be submitted (6 Medicaid payers, 6 Medicare Advantage Organizations, and 3 remaining other payers), a decrease of 65 from the 80 total requests currently approved by OMB under the aforementioned control number. We continue to estimate it will take 10 hours for a computer system analyst per arrangement submission. We estimate an annual burden of 150 hours (15 submissions x 10 hr/submission) and $14,283 (150 hr x $95.22/hr).
TABLE 30: Estimated Burden for Other Payer Advanced APM Identification Determinations: Payer-Initiated Process
Burden and Respondent Descriptions |
Burden Estimate |
# of other payer payment arrangements (6 Medicaid, 6 Medicare Advantage Organizations, 3 remaining other payers) (a) |
15 |
Total Annual Hours Per other payer payment arrangement (b) |
10 |
Total Annual Hours (c) = (a)*(b) |
150 |
Labor rate for a computer systems analyst (d) |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
$14,283 |
Under the Eligible Clinician Initiated Process, APM Entities and eligible clinicians participating in other payer arrangements have an opportunity to request that we determine for the year whether those other payer arrangements are Other Payer Advanced APMs. Eligible clinicians or APM Entities seeking to submit payment arrangement information for Other Payer Advanced APM determination through the Eligible Clinician-Initiated process are required to complete an Eligible Clinician Initiated Submission Form, instructions for which can be found at https://qpp.cms.gov/.
We are not making any changes to our currently approved estimates. As shown in Table 31, we estimate 15 other payer arrangements will be submitted by APM Entities and eligible Other Payer Advanced APM determinations in the CY 2022 MIPS performance period/2024 payment year.
We estimate it would take 10 hours at $95.22/hr for a computer system analyst per arrangement submission. In aggregate we estimate an annual burden of 150 hours (15 submissions x 10 hr/submission) at a cost of $14,283 (150 hr x $95.22/hr).
TABLE 31: Estimated Burden for Other Payer Advanced APM
Determinations:
Eligible Clinician Initiated Process
Burden and Respondent Descriptions |
Burden Estimate |
# of other payer payment arrangements from APM Entities and eligible clinicians |
15 |
Total Annual Hours Per other payer payment arrangement (b) |
10 |
Total Annual Hours (c) = (a)*(b) |
150 |
Labor rate for a computer systems analyst (d) |
$95.22/hr |
Estimated Total Annual Cost (e) = (c)*(d) |
$14,283 |
As previously discussed in the “Data Collection related to Advanced APMs” section, APM Entities or individual eligible clinicians must submit payment amount and patient count information: (1) attributable to the eligible clinician or APM Entity through every Other Payer Advanced APM; and (2) for all other payments or patients, except from excluded payers, made or attributed to the eligible clinician during the QP performance period. APM Entities or eligible clinicians must submit all of the required information about the Other Payer Advanced APMs in which they participate, including those for which there is a pending request for an Other Payer Advanced APM determination.
We are not making any changes to our currently approved estimates. As shown in Table 32, we assume that 20 APM Entities, 448 TINs, and 83 eligible clinicians will submit data for QP determinations under the All-Payer Combination Option in CY 2022. We estimate it will take the APM Entity representative, TIN representative, or eligible clinician 5 hours at $114.24/hr for a medical and health services manager to complete this submission. In aggregate, we estimate an annual burden of 2,755 hours (551 respondents x 5 hr) at a cost of $314,731 (2,755 hr x $114.24/hr).
TABLE 32: Estimated Burden for the Submission of Data for
All-Payer QP Determinations
Burden and Respondent Descriptions |
Burden Estimate |
# of APM Entities submitting data for All-Payer QP Determinations (a) |
20 |
# of TINs submitting data for All-Payer QP Determinations (b) |
448 |
# of eligible submitting data for All-Payer QP Determinations (c) |
83 |
Hours Per respondent QP Determinations (d) |
5 |
Total Hours (g) = [(a)*(d)]+[(b)*(d)]+[(c)*(d)] |
2,755 |
Labor rate for a Medical and health services manager ($114.24/hr) (h) |
$114.24/hr |
Total Annual Cost (i) = (g)*(h) |
$314,731 |
We estimate 0.1 percent of the total clinicians and groups who will voluntarily participate in MIPS will also elect not to participate in public reporting. This results in a total of 38 (0.001 x 37,934 voluntary MIPS participants) clinicians and groups, a decrease of -3,448 from the currently approved estimate of 3,486. Voluntary MIPS participants are clinicians that are not QPs and are expected to be excluded from MIPS after applying the eligibility requirements set out in the CY 2019 PFS final rule but have elected to submit data to MIPS. As discussed in section VII.F.17.c of the CY 2022 PFS proposed rule, we estimate clinicians who exceed one (1) of the low-volume criteria, but not all three (3), elected to opt-in to MIPS and submitted data in CY 2019 MIPS performance period/2021 MIPS payment year will continue to do so in CY 2022 MIPS performance period/2024 MIPS payment year.
Table 33 shows that for these voluntary participants, we estimate it will take 0.25 hours at $95.22/hr for a computer system analyst to submit a request to opt-out. In aggregate, we estimate an annual burden of 10 hours (38 requests x 0.25 hr/request) at a cost of $952 (9.5 hr x $95.22/hr).
TABLE 33: Estimated Burden for Voluntary Participants to Elect Opt Out of Performance Data Display on Physician Compare
Burden and Respondent Descriptions |
Burden Estimate |
# of Voluntary Participants Opting Out of Physician Compare (a) |
38 |
Total Annual Hours Per Opt-out Requester (b) |
0.25 |
Total Annual Hours (c) = (a)*(b) |
10 |
Labor rate for a computer systems analyst (d) |
$95.22/hr |
Total Annual Cost (e) = (c)*(d) |
$952 |
Tables 34 and 35 below provide summaries of all burden estimates for each of the information collections included in this PRA for both the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years.
TABLE 34: CY 2022 MIPS Performance Period Burden Summary
Regulation Section(s) Under Title 42 of the CFR |
Table No. |
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($)* |
§414.1400 (Registry self- nomination) |
3 |
210 |
210 |
2 |
1,137** |
95.22 |
108,266 |
§414.1400 (QCDR self-nomination) |
4 |
90 |
90 |
11.5 |
1,265** |
95.22 |
120,454 |
Open Authorization Credentialing and Token Request Process |
5 |
15 |
15 |
1 |
15 |
95.22 |
1,428 |
§414.1325 and 414.1335 (QPP Identity Management Application Process) |
9 |
3,741 |
3,741 |
1 |
3,741 |
95.22 |
356,218 |
§414.1325 and 414.1335 [(Quality Performance Category) Claims Collection Type] |
10 |
28,252 |
28,252 |
14.2 |
401,178 |
Varies (see table 10) |
40,372,673 |
§414.1325 and 414.1335 [(Quality Performance Category) QCDR/MIPS CQM Collection Type] |
11 |
52,036 |
52,036 |
9.083 |
472,643 |
Varies (see table 11) |
48,016,739 |
§414.1325 and 414.1335 [(Quality Performance Category) eCQM Collection Type] |
12 |
48,573 |
48,573 |
8.0 |
388,584 |
Varies (see table 12) |
39,812,374 |
§414.1325 and 414.1335 [(Quality Performance Category) CMS Web Interface Submission Type] |
16 |
114 |
114 |
61.7 |
7,030 |
95.22 |
669,433 |
§414.1325 and 414.1335 [(Quality Performance Category) Registration and Enrollment for CMS Web Interface] |
17 |
90 |
90 |
0.25 |
23 |
95.22 |
2,190 |
[(Quality Performance Category) Call for Quality Measures] |
18 |
28 |
28 |
5.5 |
154 |
Varies (see table 18) |
26,541 |
§414.1375 and 414.1380[(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories |
19 |
42,827 |
42,827 |
0.25 |
10,707 |
95.22 |
1,019,521 |
§414.1375 [(PI Performance Category) Data Submission] |
21 |
51,647 |
51,647 |
2.69 |
138,930 |
95.22 |
13,228,915 |
[(PI Performance Category) Call for Promoting Interoperability Measures] |
23 |
10 |
10 |
0.5 |
5 |
Varies (see table 23) |
777 |
§414.1360 [(Improvement Activities Performance Category) Data Submission] |
25 |
81,562 |
81,562 |
0.083 |
6,797 |
95.22 |
647,210 |
§414.1360 [(Improvement Activities Performance Category) Nomination of Improvement Activities] |
27 |
31 |
31 |
4.4 |
136 |
Varies (see table 27) |
20,695 |
Nomination of MVPs |
28 |
25 |
25 |
12 |
300 |
Varies (see table 28) |
46,642 |
§414.1430 [Partial Qualifying APM Participant (QP) Election] |
29 |
250 |
250 |
0.25 |
63 |
95.22 |
5,999 |
§414.1440 [Other Payer Advanced APM Identification: Payer Initiated Process] |
30 |
15 |
15 |
10 |
150 |
95.22 |
14,283 |
§414.1445 [Other Payer Advanced APM Identification: Clinician Initiated Process]
|
31 |
15 |
15 |
10 |
150 |
95.22 |
14,283 |
§414.1440 [Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option] |
32 |
551 |
551 |
5 |
2,755 |
114.24 |
314,731 |
§414.1395 [(Physician Compare) Opt Out for Voluntary Participants] |
33 |
38 |
38 |
0.25 |
10 |
95.22 |
952 |
TOTAL |
n/a |
119,890*** |
310,120 |
Varies |
1,435,773 |
Varies |
144,800,324 |
*With respect to the PRA, the CY 2022 PFS proposed rule does not impose any non-labor costs. Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
**The additional time needed for some qualified registries and QCDRs to submit targeted audits, participation plans and CAPs is included in this total.
*** Total number of unique respondents to quality, Promoting Interoperability, and improvement activity performance categories is calculated to be 118,548. Apart from extreme and uncontrollable exception applications, we assume remaining number of applications for reweighting are included in this total. We also assume all voluntary participants that opt out of Physician Compare are included in this total.
TABLE 35: CY 2023 MIPS Performance Period Burden Summary
Regulation Section(s) Under Title 42 of the CFR |
Table No. |
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($)* |
§414.1400 (Registry self- nomination) |
3 |
210 |
210 |
2 |
1,137 |
95.22 |
108,266 |
§414.1400 (QCDR self-nomination) |
4 |
90 |
90 |
11.5 |
1,265 |
95.22 |
120,454 |
Open Authorization Credentialing and Token Request Process |
5 |
15 |
15 |
1 |
15 |
95.22 |
1,428 |
§414.1325 and 414.1335 (QPP Identity Management Application Process) |
9 |
3,741 |
3,741 |
1 |
3,741 |
95.22 |
356,218 |
§414.1325 and 414.1335 [(Quality Performance Category) Claims Collection Type] |
10 |
25,427 |
25,427 |
14.2 |
361,063 |
Varies (see table 10) |
36,335,692 |
§414.1325 and 414.1335 [(Quality Performance Category) QCDR/MIPS CQM Collection Type] |
11 |
46,890 |
46,890 |
9.083 |
425,902 |
Varies (see table 11) |
43,268,216 |
§414.1325 and 414.1335 [(Quality Performance Category) eCQM Collection Type] |
12 |
43,773 |
43,773 |
8.0 |
350,184 |
Varies (see table 12) |
35,878,102 |
§ 414.1365 MVP Registration: 2023 Performance Period |
13 |
12,917 |
12,917 |
0.25 |
3,229 |
95.22 |
307,465 |
§ 414.1365 Subgroup Registration: 2023 Performance Period |
14 |
20 |
20 |
0.5 |
10 |
95.22 |
952 |
§ 414.1365 MVP Quality Submission: 2023 Performance Period |
15 |
12,917 |
12,917 |
Varies |
83,673 |
Varies (see table 15) |
8,564,736 |
[(Quality Performance Category) Call for Quality Measures] |
18 |
28 |
28 |
5.5 |
154 |
Varies (see table 18) |
26,541 |
§414.1375 and 414.1380[(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories |
19 |
42,827 |
42,827 |
0.25 |
10,707 |
95.22 |
1,019,497 |
§414.1375 [(PI Performance Category) Data Submission] |
22 |
51,667 |
51,667 |
2.69 |
138,984 |
95.22 |
13,234,078 |
[(PI Performance Category) Call for Promoting Interoperability Measures] |
23 |
10 |
10 |
0.5 |
5 |
Varies (see table 23) |
777 |
§414.1360 [(Improvement Activities Performance Category) Data Submission] |
26 |
81,582 |
81,582 |
0.083 |
6,771 |
95.22 |
644,735 |
§414.1360 [(Improvement Activities Performance Category) Nomination of Improvement Activities] |
27 |
31 |
31 |
4.4 |
136 |
Varies (see table 27) |
20,695 |
Nomination of MVPs |
28 |
25 |
25 |
12 |
300 |
Varies (see table 28) |
46,642 |
§414.1430 [Partial Qualifying APM Participant (QP) Election] |
29 |
250 |
250 |
0.25 |
63 |
95.22 |
5,999 |
§414.1440 [Other Payer Advanced APM Identification: Payer Initiated Process] |
30 |
15 |
15 |
10 |
150 |
95.22 |
14,283 |
§414.1445 [Other Payer Advanced APM Identification: Clinician Initiated Process] |
31 |
15 |
15 |
10 |
150 |
95.22 |
14,283 |
§414.1440 [Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option] |
32 |
551 |
551 |
5 |
2,755 |
114.24 |
314,731 |
§414.1395 [(Physician Compare) Opt Out for Voluntary Participants] |
33 |
38 |
38 |
0.25 |
10 |
95.22 |
952 |
TOTAL |
n/a |
119,923** |
323,039 |
Varies |
1,390,404 |
Varies |
140,284,742 |
*With respect to the PRA, the CY 2022 PFS proposed rule does not impose any non-labor costs. Due to burden for certain activities being estimated in fractions of hours, totals may not reflect the sum of individual rows due to rounding.
** Total number of unique respondents to quality, Promoting Interoperability, and improvement activity performance categories is calculated to be 118,568. With the exception of extreme and uncontrollable exception applications, we assume remaining number of applications for reweighting are included in this total. We also assume that all voluntary participants that opt out of Physician Compare are included in this total.
TABLE 36: CY 2022 and 2023 MIPS Performance Period Total Burden
Table |
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($)* |
Table 34: 2022 MIPS Performance Period Burden Summary |
119,890 |
310,120 |
Varies |
1,435,773 |
Varies |
144,800,324 |
Table 35: 2023 MIPS Performance Period Burden Summary |
119,923 |
323,039 |
Varies |
1,390,404 |
Varies |
140,284,742 |
TOTAL |
239,813 |
633,159 |
Varies |
2,826,177 |
Varies |
285,085,066 |
Information Collection Instruments/Instructions
Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sheet (Revised)
Appendix A2 (See Table 3): 2022 Qualified Registry Fact Sheet Crosswalk
Appendix B1 (See Table 4): 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet (Revised)
Appendix B2 (See Table 4): 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet Crosswalk
Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)
Appendix C2 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template Crosswalk
Appendix D1 (See Table 30): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)
Appendix D2 (See Table 30): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations Crosswalk (Payer Initiated Submission Form)
Appendix E1 (See Table 31): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) (Revised)
Appendix E2 (See Table 31): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) Crosswalk
Appendix F1 (See Table 32): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)
Appendix F2 (See Table 32): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option Crosswalk
Appendix G1 (See Table 18): Measures under Consideration 2021, Data Template for Candidate Measures (Revised)
Appendix G2 (See Table 18): Measures under Consideration 2021, Data Template for Candidate Measures Crosswalk
Appendix H1 (See Table 18): 2022 Peer Reviewed Journal Article Requirement Template (Revised)
Appendix H2 (See Table 18): 2022 Peer Reviewed Journal Article Requirement Template Crosswalk
Appendix I1 (See Table 23): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)
Appendix I2 (See Table 23): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form Crosswalk
Appendix J1 (See Table 27): Improvement Activities Performance Category, 2021 Call for Activities Submission Form (No change)
Appendix K1 (See Table 19): 2021 Hardship Exception Application Form (No change)
Appendix L1 (See Table 19): 2021 Extreme and Uncontrollable Circumstances Application Form (No change)
Appendix M (See Table 28): 2021 MVP Candidates: Instructions and Template (No change)
Appendix N1 (See Table 16): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (Revised)
Appendix N2 (See Table 16): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide Crosswalk
Appendix O1 (See Table 29): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)
We propose to sunset the CMS Web Interface measures as a collection type for groups and virtual groups with 25 or more eligible clinicians starting with the CY 2023 MIPS performance period/2025 MIPS payment year. We recognize that the proposed sunset of the CMS Web Interface for groups and virtual groups may be burdensome to current groups and virtual groups submitting quality data on CMS Web Interface measures. Such groups and virtual groups would need to select a different collection type/submission type and redesign their systems to be able to interact with the new collection type/submission type. Given that the Medicare Part B claims collection type is limited to small practices, the alternatives for these groups and virtual groups would be either the MIPS CQM, QCDR, or eCQM collection types. Given the size of the affected groups and virtual groups, we believe the majority are likely to already be using a QCDR, qualified registry, or EHR as part of their practice workflow. Of the 3,611 TINs comprised of 25 or more clinicians who submitted MIPS data via a collection type other than the CMS Web Interface, 56 percent reported via the MIP CQM and QCDR collection type and 44 percent reported via the eCQM collection type. For groups converting from Web Interface, there will be some non-recurring costs associated with modifying clinical and MIPS data reporting workflows to utilize an alternate collection type. For any remaining groups and virtual groups there will also be registry fees paid to a QCDR or qualified registry or the financial expense of purchasing/licensing and deploying an EHR system. Because we are unable to assess either the existing workflows of each individual group and virtual group or the decisions each group and virtual group will make in response to this policy, we cannot quantify the resulting economic impact. While there may be an initial increase in burden for current groups and virtual groups utilizing the CMS Web Interface measures having to transition to the utilization of a different collection type/submission type, we recognize that we would also be reducing reporting requirements. Groups and virtual groups would no longer have to completely report on all pre-determined CMS Web Interface measures and would be able to select their own measures (at least 6) to report.
Groups and virtual groups account for less than 20 percent of organizations utilizing the CMS Web Interface measures while ACOs participating in the Medicare Shared Savings Program and Next Generation ACO Model account for more than 80 percent. In assessing the utilization of the CMS Web Interface by groups and virtual groups, there has been a substantial decrease in participation each year since the inception of MIPS in the 2017 performance period. From 2017 to 2019, the number of groups eligible to report quality measures via the CMS Web Interface (groups registered to utilize the CMS Web Interface) decreased by approximately 45 percent. Similarly, the number of groups utilizing the CMS Web Interface as a collection type decreased by approximately 40 percent from 2017 to 2019 (85 FR 85020 through 85021).
Aside from program administrative and implementation costs, MIPS payment incentives and penalties are budget-neutral and present no cost to the federal government, with respect to the application of the MIPS payment adjustments.
In the CY 2021 PFS final rule (85 FR 84884 through 84885), we stated to consider agency-nominated improvement activities beginning with the CY 2021 MIPS performance period/2023 MIPS payment year and future years. As discussed in the CY 2021 PFS final rule (85 FR 85021), we are unable to estimate the number of improvement activity nominations we will receive. Therefore, we continue to assume it will require 3 hours at $58.76/hr for a GS-13 Step 5 to nominate an improvement activity for a total cost of $176.28 (3 hrs x $58.76/hr) per activity.
Due to the proposed policy to continue the CMS Web Interface measures as a collection type/submission type for the CY 2022 MIPS performance period/ 2024 MIPS payment year, the federal government will continue to fund the operation and maintenance of the CMS Web Interface measures, the establishment and maintenance of benchmarks, and the provision of technical support, education, and outreach. The proposed policy to sunset the CMS Web Interface measures as a collection type/submission type beginning with the CY 2023 MIPS performance period/2025 MIPS payment year will result in cost savings to the federal government as it will no longer be required to operate and maintain the CMS Web Interface measures, establish and maintain benchmarks, conduct assignment and sampling, and provide technical support, education, and outreach.
In this section, we have included the proposed change in estimated burden for the CY 2022 and CY 2023 MIPS performance periods due to the proposed policies and information collections in the CY 2022 PFS proposed rule.
To help readers better navigate through all of the proposed changes, this section deviates from the COI (Collection of Information) section of the proposed rule. While the end result is the same, this section reformats the information into a more logical and easier to follow presentation. What differs is how each CY of burden compares with others. Specifically:
For CY 2021 we subtract all of the CY 2021 burden that was set out in the CY 2021 final rule’s Supporting Statement. The figures are negative since they are being removed.
For CY 2022 we adjust (+/-) all of the CY 2022 burden that was set out in the CY 2021 final rule’s Supporting Statement by comparing/contrasting this with section 12 of this CY 2022 proposed rule’s Supporting Statement.
For CY 2023 we add all of the CY 2023 burden that is set out in section 12 of the CY 2022 proposed rule’s Supporting Statement. All of the figures are positive (added) since this is new burden.
The proposed policies in the CY 2022 PFS proposed rule impact the burden estimates for the CY 2022 and CY 2023 MIPS performance periods. However, our currently approved burden estimates for the CY 2021 MIPS performance period (85 FR 84958 through 84998) approved by OMB on May 28, 2021, included estimated burden due to finalized policies and assumptions for the CY 2021 and CY 2022 MIPS performance periods. The currently approved estimated burden for the package does not include the CY 2023 MIPS performance period. In order to understand the burden implications of the policies proposed in the CY 2022 PFS proposed rule relative to the current package that was approved by OMB on May 28, 2021:
We have subtracted the burden for the policies and information collections set forth for the CY 2021 MIPS performance period/2023 MIPS payment year in the CY 2021 PFS final rule (see table 37).
We have revised our burden estimates for the CY 2022 MIPS performance period/2024 MIPS payment year due to proposed policies in the CY 2022 PFS proposed rule and changes for continuing the policies and information collections set forth in the CY 2021 PFS final rule into the CY 2022 MIPS performance period/2024 MIPS payment year (see table 38 with additional information in tables 38A through 38U).
We are setting forth new burden for the CY 2023 MIPS performance period/2025 MIPS payment year (see tables 40 and 41).
Due to the multiple performance periods included in the currently approved burden set forth in the CY 2021 PFS final rule for this package, we believe that the above approach would help readers easily understand and follow the changes in the estimated burden due to the proposed policies and assumptions in the CY 2022 PFS proposed rule relative to the currently approved burden for this package.
a. CY 2021 MIPS Performance Period/2023 MIPS Payment Year Burden
The currently approved burden estimate for the policies and information collections in the CY 2021 MIPS performance period was set forth in the CY 2021 PFS final rule. This burden is associated with the policies and information collections for the CY 2021 MIPS performance period/CY 2023 MIPS payment year and is not relevant to the proposed policies and information collections in the CY 2022 and CY 2023 MIPS performance periods/CY 2024 and 2025 MIPS payment years, set forth in the CY 2022 PFS proposed rule. Therefore, as shown in table 37, we subtracted this burden in our burden calculations for the CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years.
TABLE 37: Change in Burden for CY 2021 MIPS Performance Period/2023 MIPS Payment Year
|
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($)* |
2021 MIPS Performance Period Burden Summary |
(123,619) |
(327,126) |
Varies |
(1,481,468) |
Varies |
(145,245,912) |
CY 2022 MIPS Performance Period/2024 MIPS Payment Year Burden
We have revised Appendices A1 (2022 Qualified Registry Fact Sheet), B1 (2022 QCDR Fact Sheet), C1 (2022 QCDR Measure Submission Template), D1 (Payer Initiated Submission Form), E1 (Eligible Clinician Initiated Submission Form), F1 (Requests form for QP Determinations under the All-Payer Combination Option), G1 (2021 Measures Under Consideration Data Template), H1 (Peer Reviewed Journal Article Requirement Template), I1 (Call for Promoting Interoperability Measures Submission Form), and N1 (CMS Web Interface and CAHPS for MIPS Registration Guide) which are included in this PRA submittal to reflect changes due to revised terminology as well as to provide additional clarity. Crosswalks have been provided in Appendices A2, B2, C2, D2, E2, F2, G2, I2, and N2 which describe all changes from previous submittals. Also included in this PRA is one new appendix: O (Partial QP Election Form). We have been capturing the burden associated with completing this form, however, we want to note that the actual form was not included in previous PRA packages.
TABLE 38: Change in Burden for CY 2022 MIPS Performance
Period/
2024 MIPS Payment Year
Burden Type |
Total Requested (A) |
Change Due to New Statute (B) |
Change Due to Program Discretion (C) |
Change Due to Program Adjustment (D) |
Total Currently Approved (E)
(2022 MIPS Performance Period) |
Total Responses |
310,120 |
-13,775* |
0 |
-3,141 |
327,036 |
Total Time (hr) |
1,435,773 |
+3,620** |
0 |
-43,383 |
1,475,536 |
Total Cost ($) |
144,800,324
|
+340,778 |
0 |
-4,168,646 |
*-13,775 responses = 19 (Table 38A) + 10 (Table 38B) - 45 (Table 38F) - 66 (Table 38G) + 111 (Table 38H) - 13,894 (Table 38K) + 90 (Table 38I)
**+3,621 hours = 57 (Table 38A) + 30 (Table 38B) - 409 (Table 38F) - 528 (Table 38G) + 6,845 (Table 38K) + 23 (Table 38L) -3,474 (Table 38K) + 1,033 (Table 38L) + 43 (Table 38O)
As shown above in table 38, the decrease of -13,775 responses with a total burden of +3,620 hours at a cost of +$340,778 due to new statutes (Column B) is due to the proposed policies to require QCDRs and qualified registries to submit participation plans if necessary, the decrease in the estimated number of respondents submitting quality data via the MIPS CQM and QCDR collection types due to the proposal to extend the CMS Web Interface as a collection type for the CY 2022 MIPS performance period/2024 MIPS payment year, the decrease in the estimated number of respondents submitting quality data via the eCQM collection type due to the proposal to extend the CMS Web Interface as a collection type for the CY 2022 MIPS performance period/2024 MIPS payment year, an increase in the number of respondents submitting data via the CMS Web Interface collection type, an increase in the number of respondents registering for the CMS Web Interface, a decrease in the number of respondents submitting reweighting applications due to the proposed policy for automatic reweighting of the Promoting Interoperability performance category for small practices, the proposed new criteria for nomination of improvement activities, and the proposed policy for annual assessment of SAFER Guides requirement in the Promoting Interoperability performance category. The remaining changes due to program adjustment (Column D) are entirely due to availability of updated data. Table series 38 below provides additional detail as to the changes in burden for each information collection.
TABLE 38A: Burden Reconciliation for Qualified Registry Self-Nomination and Other Requirements
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
183 |
1 |
183 |
3 |
1,139* |
95.22 |
108,456 |
Proposed (2022 MIPS Performance Period) (See Table 3) |
210 |
1 |
210 |
2 |
1,137* |
95.22 |
108,266 |
Adjustment |
+27 |
No change |
+27 |
-1 |
-2 |
No change |
-190 |
* The additional time needed for some qualified registries to submit targeted audits, participation plans, and CAPs is included in this total.
TABLE 38B: Burden Reconciliation for QCDR Self-Nomination and other Requirements
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
82 |
1 |
82 |
8 |
826 |
95.22 |
78,652 |
Proposed (2022 MIPS Performance Period) (See Table 4) |
90 |
1 |
90 |
11.5 |
1265 |
95.22 |
120,454 |
Adjustment |
+8 |
No change |
+8 |
+3.5 |
+439 |
No change |
+41,802 |
TABLE 38C: Burden Reconciliation for Open Authorization Credentialing and Token Request Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
15 |
1 |
15 |
1 |
15 |
95.22 |
1,428 |
Proposed (2022 MIPS Performance Period) (See Table 5) |
15 |
1 |
15 |
1 |
15 |
95.22 |
1,428 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 38D: Burden Reconciliation for Quality Payment Program Identity Management Application Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
3,741 |
1 |
3,741 |
1 |
3,741 |
95.22 |
356,218 |
Proposed (2022 MIPS Performance Period) (See Table 9) |
3,741 |
1 |
3,741 |
1 |
3,741 |
95.22 |
356,218 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 38E: Burden Reconciliation for Quality Performance Category Claims Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
29,273 |
1 |
29,273 |
14.2 |
415,677 |
Varies |
41,630,421 |
Proposed (2022 MIPS Performance Period) (See Table 10) |
28,252 |
1 |
28,252 |
14.2 |
401,178 |
Varies |
40,372,673 |
Adjustment |
-1,021 |
No change |
-1,021 |
No change |
-14,499 |
No change |
-1,257,748 |
TABLE 38F: Burden Reconciliation for Quality Performance Category QCDR/MIPS CQM Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
52,944 |
1 |
52,944 |
9.083 |
480,890 |
Varies |
48,854,605 |
Proposed |
52,036 |
1 |
52,036 |
9.083 |
472,643 |
Varies |
48,016,739 |
Adjustment |
-908 |
No change |
-908 |
No change |
-8,247
|
No change |
-837,696
|
TABLE
38G: Burden Reconciliation for Quality Performance Category
eCQM
Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
50,475 |
1 |
50,475 |
8 |
403,800 |
Varies |
41,371,329
|
Proposed (See Table 12) |
48,573 |
1 |
48,573 |
8 |
388,584 |
Varies |
39,812,374 |
Adjustment |
-1,902 |
No change |
-1,902 |
No change |
-15,216
|
No change |
-1,558,955 |
TABLE 38H: Burden Reconciliation for Quality Performance Category CMS Web Interface Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Proposed |
114 |
1 |
114 |
61.7 |
7,030 |
95.22 |
669,433 |
Adjustment |
+114 |
1 |
+114 |
+61.7 |
+7,030 |
95.22 |
+669,433 |
TABLE 38I: Burden Reconciliation for Quality Performance Category Group Registration for the CMS Web Interface
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Proposed (2022 MIPS Performance Period) (See Table 17) |
90 |
1 |
90 |
0.25 |
23 |
95.22 |
2,190 |
Adjustment |
+90 |
1 |
+90 |
0.25 |
+23 |
95.22 |
+2,190 |
TABLE 38J: Burden Reconciliation for Call for Quality Measures
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
28 |
1 |
28 |
5.5 |
154 |
Varies |
30,870 |
Proposed (2022 MIPS Performance Period) (See Table 18) |
28 |
1 |
28 |
5.5 |
154 |
Varies |
26,541 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
-$4,329 |
TABLE 38K: Burden Reconciliation for Reweighting Applications for Promoting Interoperability and Other Performance Categories
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
52,099 |
1 |
52,099 |
0.25 |
13,025 |
95.22 |
1,240,241 |
Proposed (2022 MIPS Performance Period) (See Table 19) |
42,827 |
1 |
42,827 |
0.25 |
10,707 |
95.22 |
1,019,521 |
Adjustment |
-9,272
|
No change |
-9,272
|
No change |
-2,318
|
No change |
-220,720 |
TABLE 38L: Burden Reconciliation for Promoting Interoperability Performance Category Data Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
53,636 |
1 |
53,636 |
2.67 |
143,208 |
95.22 |
13,636,266 |
Proposed (2022 MIPS Performance Period) (See Table 21) |
51,647 |
1 |
51,647 |
2.69 |
138,930 |
95.22 |
13,228,915 |
Adjustment |
-1,989 |
No change |
-1,989 |
+0.02 |
-4,278 |
No change |
-$407,351 |
TABLE 38M: Burden Reconciliation for Call for Promoting Interoperability Measures
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
10 |
1 |
10 |
0.5 |
5 |
Varies |
777 |
Proposed (2022 MIPS Performance Period) (See Table 23) |
10 |
1 |
10 |
0.5 |
5 |
Varies |
777 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 38N: Burden Reconciliation for Improvement Activities Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
79,927 |
1 |
79,927 |
0.083 |
6,661 |
95.22 |
634,221 |
Proposed (2022 MIPS Performance Period) (See Table 25) |
81,562 |
1 |
81,562 |
0.083 |
6,797 |
95.22 |
647,210 |
Adjustment |
+1,635 |
No change |
+1,635 |
No change |
+136 |
No change |
+$12,989 |
TABLE 38O: Burden Reconciliation for Nomination of Improvement Activities
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
31 |
1 |
31 |
3 |
93 |
Varies |
14,203 |
Proposed (2022 MIPS Performance Period) (See Table 27) |
31 |
1 |
31 |
4.4 |
136 |
Varies |
20,695 |
Adjustment |
No Change |
No Change |
No change |
+1.4 |
+43 |
Varies |
+$6,492 |
TABLE 38P: Burden Reconciliation for Nomination of MVPs
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
25 |
1 |
25 |
12 |
300 |
Varies |
46,642 |
Proposed (2022 MIPS Performance Period) (See Table 28) |
25 |
1 |
25 |
12 |
300 |
Varies |
46,642 |
Adjustment |
No change |
No change |
+ No change |
No change |
No change |
No change |
No change |
TABLE 38Q: Burden Reconciliation for Partial QP Election
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
300 |
1 |
300 |
0.25 |
75 |
95.22 |
7,142 |
Proposed (2022 MIPS Performance Period) (See Table 29) |
250 |
1 |
250 |
0.25 |
63 |
95.22 |
5,999 |
Adjustment |
-50 |
No change |
-50 |
No change |
-12 |
No change |
-$1,143 |
TABLE 38R: Burden Reconciliation for Other Payer Advanced APM Identification: Other Payer Initiated Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
80 |
1 |
80 |
10 |
800 |
95.22 |
76,176 |
Proposed (2022 MIPS Performance Period) (See Table 30) |
15 |
1 |
15 |
10 |
150 |
95.22 |
14,283 |
Adjustment |
-65 |
No change |
-65 |
No change |
-650 |
No change |
-$61,893
|
TABLE 38S: Burden Reconciliation for Other Payer Advanced APM Identification: Eligible Clinician Initiated Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
150 |
1 |
150 |
10 |
1,500 |
95.22 |
142,830 |
Proposed (2022 MIPS Performance Period) (See Table 31) |
15 |
1 |
15 |
10 |
150 |
95.22 |
14,283 |
Adjustment |
-135 |
No change |
-135 |
No change |
-1,350 |
No change |
-$128,547 |
TABLE 38T: Burden Reconciliation for Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
551 |
1 |
551 |
5 |
2,755 |
114.24 |
314,731 |
Proposed (2022 MIPS Performance Period) (See Table 32) |
551 |
1 |
551 |
5 |
2,755 |
114.24 |
314,731 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 38U: Burden Reconciliation for Voluntary Participants to Elect to Opt Out of Performance Data Display on Physician Compare
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved (2022 MIPS Performance Period) |
3,486 |
1 |
3,486 |
0.25 |
872 |
95.22 |
82,984 |
Proposed (2022 MIPS Performance Period) (See Table 33) |
38 |
1 |
38 |
0.25 |
10 |
95.22 |
952 |
Adjustment |
-3,448 |
No change |
-3,448 |
No change |
-862
|
No change |
-$82,032 |
Table 39 provides the reasons for changes in the estimated burden for proposed policies and information collections for the CY 2022 MIPS performance period set forth in the CY 2022 PFS proposed rule. We have divided the reasons for our change in burden into those related to newly proposed policies and those related to updated data and methods for the CY 2022 MIPS performance period burden set forth in the CY 2021 PFS final rule.
TABLE 39: Reasons for Change in Burden Compared to the Currently
Approved
CY 2021 Information Collection Burdens
Table in Collection of Information |
Changes in burden due to proposed CY 2022 policies |
Changes to "baseline" of burden continued CY 2021 policy |
Table 3: Qualified Registry Self-Nomination and Other Requirements |
Increase in burden due to the proposed policy requiring submission of participation plans, as necessary (3 hours per plan).
|
Decrease in the estimated number of hours required for full-self nomination process. |
Table 4: QCDR Self-Nomination and Other Requirements |
Increase in burden due to the proposed policy requiring submission of participation plans, as necessary (3 hours per plan). Increase in burden due to current policies not previously having a burden estimate. (QCDR pre-existing measures) |
Increase in number of hours required for simplified and full self-nomination process. |
Table 5: Open Authorization Credentialing and Token Request Process |
None |
None |
Table 9: Quality Payment Program Identity Management Application Process |
None |
None |
Table 10: Quality Performance Category Claims Collection Type |
None |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year and updated QP projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 11: Quality Performance Category QCDR/MIPS CQM Collection Type |
Decrease in the number of respondents due to the proposed policy to extend the CMS Web Interface measures as a collection type/submission type for the CY 2022 MIPS performance period/2024 MIPS payment year.
|
Decrease in number of respondents due to updated projections from the CY 2022 MIPS performance period/2024 MIPS payment year and updated QP projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 12: Quality Performance Category eCQM Collection Type |
Decrease in the number of respondents due to the proposed policy to extend the CMS Web Interface measures as a collection type/submission type for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year and updated QP projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 16: Quality Performance Category CMS Web Interface Collection Type |
Addition of information collection due to the proposed policy to extend the CMS Web Interface measures as a collection type/submission type. |
Increase in number of respondents (+114) due to proposed policy to extend the CMS Web Interface measures as a collection type/submission type.
. |
Table 17: Group Registration for CMS Web Interface |
Addition of information collection due to the proposed policy to extend the CMS Web Interface measures as a collection type/submission type.
|
Increase in number of respondents (+90) due to proposed policy to extend the CMS Web Interface measures as a collection type/submission type.
|
Table 18: Call for Quality Measures |
None |
None |
Table 19: Reweighting Applications for Promoting Interoperability and Other Performance Categories |
Decrease in the number of respondents due to the proposed policy to allow automatic reweighting of the Promoting Interoperability performance category for small practices |
None |
Tables 21 and 22: Promoting Interoperability Performance Category Data Submission |
Increase in per response burden (+0.02 hours) due to the proposed policy for annual assessment SAFER Guides requirement
|
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year and updated QP projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 23: Call for Promoting Interoperability Measures |
None. |
None. |
Tables 24 and 25: Improvement Activities Submission |
(CY 2023 MIPS Performance Period/2025 MIPS Payment Year) Increase in number of respondents (+20) due to the proposed implementation of subgroup reporting for MVPs. |
Increase in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year |
Table 27: Nomination of Improvement Activities |
Increase in per response burden (+1.4 hours) due to the proposed revised criteria for nomination of improvement activities. |
None. |
Table 28: Nomination of MVPs |
None |
None |
Table 29: Partial QP Election |
None |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 30: Other Payer Advanced APM Identification: Other Payer Initiated Process |
None. |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 31: Other Payer Advanced APM Identification: Eligible Clinician Initiated Process |
None. |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
Table 32: Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option |
None. |
None. |
Table 33: Voluntary Participants to Elect to Opt Out of Performance Data Display on Physician Compare |
None. |
Decrease in number of respondents due to updated projections for the CY 2022 MIPS performance period/2024 MIPS payment year. |
CY 2023 MIPS Performance Period/2025 MIPS Payment Year Burden
As discussed above, we are setting forth the burden estimates for the CY 2023 MIPS performance period/2025 MIPS payment year as new burden. For the purposes of comparison, we are showing the difference between our CY 2023 and CY 2022 burden estimates the Table 40 below. Overall, the CY 2023 burden increases our CY 2022 estimates by 31 respondents and 12,919 responses, while reducing our CY 2022 estimates by 45,369 hours, and $4,515,572. To help readers streamline their review of this document we are not repeating the CY 2023 burden discussion as it would be redundant since it is already in Section 12 (see Table 35). For the readers convenience, however, we are repeating the CY 2023 burden in the first row of the following table:
TABLE 40: Burden for CY 2023 MIPS Performance Period/
2025
MIPS Payment Year
Burden Category |
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($) |
Table 35: 2023 MIPS Performance Period Burden Summary (CMS-1751-P) |
119,923 |
323,039 |
Varies |
1,390,404 |
Varies |
140,284,742 |
Table 34: 2022 MIPS Performance Period Burden Summary (CMS-1751-P) |
-119,890 |
-310,120 |
Varies |
-1,435,773 |
Varies |
-144,800,324 |
DIFFERENCE |
33 |
12,919 |
Varies |
-45,369 |
Varies |
-4,515,482 |
In our burden calculations for the CY 2023 MIPS performance period/2025 MIPS payment year, we have included the following estimates due to the proposed policies in the CY 2022 PFS proposed rule: 1) to sunset the CMS Web Interface beginning in the CY 2023 MIPS performance period/2025 MIPS payment year, 2) to implement voluntary MVP and subgroup reporting option beginning with the CY 2023 MIPS performance period, 3) the changes in the number of respondents submitting quality data via the MIPS CQM and QCDR collection type, eCQM and claims collection types due to the proposed MVP and subgroup participation options, and 4) the changes in the number of respondents submitting data for the Promoting Interoperability and the improvement activities performance categories due to the proposed MVP and subgroup participation options.
Table 41 represents the change in burden for the CY 2023 MIPS performance period/2025 MIPS payment year. As stated above in this section, there is no currently approved burden in the existing package for the CY 2023 MIPS performance period/2025 MIPS payment year. To accurately capture the change in burden for the policies and information collections set forth in the CY 2022 PFS proposed rule for the CY 2023 MIPS performance period, the proposed estimated burden will be submitted to OMB for approval as a new request.
TABLE 41: Change in Burden for CY 2023 MIPS Performance
Period/
2025 MIPS Payment Year
Burden Type |
Total Requested (A) |
Change Due to New Statute (B) |
Change Due to Program Discretion (C) |
Change Due to Program Adjustment (D) |
Total Currently Approved (E)
|
Total Responses |
323,039 |
+323,039 |
N/A |
N/A |
N/A |
Total Time (hr) |
1,390,404 |
+1,390,404 |
N/A |
N/A |
N/A |
Total Cost ($) |
140,284,742 |
+140,284,742 |
N/A |
N/A |
N/A |
Table 42: Burden Impact: CY 2021, 2022, and 2023 MIPS Performance Periods
Burden Category |
No. Respondents |
Responses |
Time per Response (hours) |
Total Annual Time (hours) |
Labor Cost ($/hr) |
Total Cost ($)* |
Currently Approved by OMB (A) |
247,148 |
654,162 |
Varies |
2,957,004 |
Varies |
289,949,842 |
2021 MIPS Performance Period (see Table 37) (B) |
-123,619 |
-327,126 |
Varies |
-1,481,468 |
Varies |
-145,245,912 |
2022 MIPS Performance Period (see Table 38) (C) |
119,890 |
-16,916 |
Varies |
-39,763 |
Varies |
96,394 |
2023 MIPS Performance Period (see Table 41) (D) |
119,923 |
323,039 |
Varies |
1,390,404 |
Varies |
140,284,742 |
Subtotal of Changes (E) = (B) + (C) + (D) |
116,194 |
-21,003 |
varies |
-130,827 |
varies |
-4,864,776 |
Total Requested (F) = (A) + (B) + (C) + (D) |
119,907 (two-year average) |
633,159 |
Varies |
2,826,177 |
Varies |
285,085,066 |
* With respect to the PRA, the CY 2022 PFS proposed rule does not impose any non-labor costs. The discrepancy in the amounts included in the “Total Cost” column between table 42 and table 38 is due to the updated wage estimates.
In order to provide expert feedback to clinicians and third party data submitters in order to help clinicians provide high-value, patient-centered care to Medicare beneficiaries; we provide performance feedback to MIPS eligible clinicians that includes MIPS quality, cost, improvement activities and Promoting Interoperability data; MIPS performance category and final scores; and payment adjustment factors. These reports were made available starting in July 2018 at qpp.cms.gov. We have also provided performance feedback to MIPS eligible clinicians who participate in MIPS APMs in 2018 and future years as technically feasible. This reflects our commitment to providing as timely information as possible to eligible clinicians to help them predict their performance in MIPS.
MIPS information is publicly reported through the Care Compare website (https://www.medicare.gov/care-compare/) both on public profile pages and via the Downloadable Database as discussed at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/. 2017, 2018, and 2019 Quality Payment Program performance information has been made available for public review.
We plan to provide relevant data to other federal and state agencies, Quality Improvement Networks, and parties assisting consumers, for use in administering or conducting federally funded health benefit programs, payment and claims processes, quality improvement outreach and reviews, and transparency projects.
The expiration date is displayed on all web-based data collection forms.
There are no exceptions to the certification statement.
1 Cost performance category measures do not require the collection of additional data because they are derived from the Medicare Parts A and B claims.
2 The use of CMS-approved survey vendors is not included in this PRA package. CMS has requested approval for the collection of CAHPS for MIPS data via CMS-approved survey vendors in a separate PRA package (OMB Control Number 0938-1222).
3 For further detail on MIPS exclusions, see Supporting Statement B and the Regulatory Impact Analysis Section of the CY 2022 PFS proposed rule.
4 Lawrence P. Casalino et al, “US Physician Practices Spend More than $15.4 Billion Annually to Report Quality Measures,” Health Affairs, 35, no. 3 (2016): 401-406.
5 We do not anticipate any changes in the CEHRT process for health IT vendors as we transition to MIPS. Hence, health IT vendors are not included in the burden estimates for MIPS.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | MIPS Supporting Statement - Part A (CMS-10621, OMB 0938-1314) |
| File Modified | 0000-00-00 |
| File Created | 2021-10-05 |