Supporting Statement – Part A
Quality Payment Program (QPP)/Merit-Based Incentive Payment System (MIPS)
CMS-10621, OMB 0938-1314
The Merit-based Incentive Payment System (MIPS) is a program for MIPS eligible clinicians that makes Medicare payment adjustments based on performance in the quality, cost, Promoting Interoperability, and improvement activities performance categories. MIPS and Advanced Alternative Payment Models (AAPMs) are the two paths available for clinicians 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 performance areas: quality – a set of evidence-based, specialty-specific standards; improvement activities that focus on practice-based improvements; 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. 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, groups, and subgroups will have the option to submit data using various submission types, including Medicare claims, direct, log in and upload, and CMS-approved survey vendors.2 For the improvement activities and Promoting Interoperability performance categories, MIPS eligible clinicians, groups, and subgroups can submit data through direct, log in and upload, or log in and attest submission types. We finalized in the CY 2022 PFS final rule that a subgroup participating in MVP reporting will submit its affiliated group’s data for the Promoting Interoperability performance category, and in the scenario that a subgroup does not submit its affiliated group’s data, the subgroup will receive a zero score for the Promoting Interoperability performance category (86 FR 65413 through 65414).
As finalized in the CY 2021 PFS final rule (85 FR 84860), for clinicians in APM Entities, the APM Performance Pathway (APP) 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 APP versus the traditional MIPS submission mechanism for the CY 2024 performance period/2026 MIPS payment year, we assume ACO APM Entities will submit data through the APP, 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 note that the CMS Web Interface is available as a collection type/submission type through the CY 2024 performance period/2026 MIPS payment year only for clinicians in Shared Savings Program reporting the APM Performance Pathway.
Beginning with January 1 of the CY 2023 performance period/2025 MIPS payment year, individual clinicians, groups, and APM Entities can choose to report the measures and activities in a MIPS Value Pathway (MVP). Beginning with the CY 2023 performance period/2025 MIPS payment year, clinicians can choose to participate as subgroups to report the measures and activities in an MVP. We note that the subgroup reporting option is not available for clinicians participating in traditional MIPS.
For the improvement activities performance category, we finalized changes to the improvement activities inventory for the CY 2024 performance period/2026 MIPS payment year and future years as follows: adding 5 new improvement activities; modifying 1 existing improvement activity; and removing 3 previously adopted improvement activities.
The implementation of MIPS requires the collection of additional data beyond performance category data submission. Additionally, there are information collections related to AAPMs. Please see sections 12 and 15 of this Supporting Statement for details.
We are requesting approval of 25 information collections associated with the CY 2024 PFS final rule as a revision to our currently approved information requests submitted under this package’s control number (OMB 0938-1314, CMS-10621). CMS has already received approval for the collection of information associated with the virtual group election process under OMB control number 0938-1343 (CMS-10652). CMS requested the approval for estimated burden related to the collection of information associated with the CAHPS for MIPS survey under OMB control number 0938-1222 (CMS-10450).
The changes in this CY 2024 collection of information request are associated with our November 16, 2023 (88 FR 78818) final rule (CMS-1784-F, RIN 0939-AV07).
Where updated data and assumptions were available for the CY 2024 PFS final rule, we have adjusted the applicable ICRs. We estimate a decrease in burden of 8,798 hours and $1,009,345 for the CY 2024 performance period/2026 MIPS payment year due to updated data and assumptions as well as policies finalized in the CY 2024 PFS final rule. As noted in section 8 of this Supporting Statement, we have updated our estimated burden submitted in the CY 2024 NPRM MIPS PRA package due to the availability of updated data for the CY 2024 performance period/2026 MIPS payment year.
As discussed in sections 12 and 15 of this Supporting Statement, the finalized policies in the CY 2024 PFS final rule will result in a decrease in burden for the ICRs related to the data submission via the Medicare Part B Claims, MIPS clinical quality measure (CQM), qualified clinical data registry (QCDR), and electronic clinical quality measure (eCQM) collection types for the quality performance category. The policies will also result in an increase in the burden for the ICRs related to the MVP quality performance category submission and MVP registration. The remaining changes to our currently approved burden estimates are adjustments due to the use of updated data sources and assumptions.
We are requesting to add two new ICRs, “simplified qualified registry self-nomination process” and “simplified QCDR self-nomination process,” to distinctly capture the burden for the number of QCDRs and qualified registries submitting applications for the simplified and full self-nomination process. We note that the addition of these ICRs is not due to the policy changes relevant to third party intermediaries in the CY 2024 PFS final rule. It is a change in our approach to representing the estimated burden for the third-party intermediary self-nomination process due to availability of updated data.
We are also requesting to remove one ICR, “nomination of Promoting Interoperability measures.” We note that the removal of the ICR is not due to policy changes in the CY 2024 PFS final rule. It is due to a consistent decline in the number of submissions received for the ICR.
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 through the CY 2022 performance period/2024 MIPS payment year. The APM incentive payment was extended for one additional year for clinicians who are QPs in the CY 2023 performance period/2025 MIPS payment year.
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 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.
Relevant data will be provided to federal and state agencies, Quality Improvement Networks, contractors supporting the Quality Payment Program, 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 document 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 would not need to submit improvement activities because they will be reporting through the APM Performance Pathway (APP). For the CY 2024 performance period/2026 MIPS payment year, we assume that all MIPS APM models would qualify for the maximum improvement activities performance category score and the APM Entities reporting the APP would not need to submit any additional improvement activities. We assume ACO APM Entities would submit data through the APM Performance Pathway and non-ACO APM Entities would participate through traditional MIPS, thereby submitting as an individual or a 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 2024 PFS final rule’s Regulatory Impact Analysis estimates that approximately 686,650 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 129,806 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 405,940 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 420,287 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.
Data on the quality, Promoting Interoperability, and improvement activities performance categories are collected from individual MIPS eligible clinicians, groups, or subgroups annually. If this information were collected less frequently, we would have no mechanism to: (1) determine whether a MIPS eligible clinician, group, or a subgroup 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 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 qualified 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.
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.
The CY 2024 PFS proposed rule served as the 60-day notice which published in the Federal Register on August 7, 2023 (88 FR 52262, CMS-1784-P; RIN 0938-AV07). The rule was placed for public inspection on July 13, 2023. We did not receive public comments for our estimated burden in the CY 2024 performance period/2026 MIPS payment year.
In the CY 2024 PFS proposed rule PRA package, we estimated a total of 715,450 hours with a total cost of $80,522,391 for the CY 2024 performance period/2026 MIPS payment year. In the CY 2024 PFS final rule PRA package, we are revising our estimate to 728,142 hours and $82,202,558. This is an increase in burden of 12,692 hours and an increase of $1,680,167 in the labor cost.
We have more recent data available and therefore, updated our estimates submitted in the CY 2024 NPRM MIPS PRA package. See sections 12 and 15 of this Supporting Statement for details.
The CY 2024 PFS final rule (CMS-1784-F, RIN 0938-AV07) published in the Federal Register on November 16, 2023 (88 FR 78818).
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 2022 National Occupational Employment and Wage Estimates for all salary estimates (https://www.bls.gov/oes/2022/may/oes_nat.htm). In this regard, Table 1 presents the mean hourly wage, the cost of fringe benefits and other indirect costs (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 other indirect 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
For our purposes, the BLS’ May 2022 National Occupational Employment and Wage Estimates does not provide an occupation that we could use for “Physician” wage data. As a result, in order to estimate the cost for “Physicians”, we are using a rate of $274.44/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 Orthopedic Surgeons, Except Pediatric; Psychiatrists; Pediatric Surgeons; Surgeons, All Other; and Surgeons, Except Ophthalmologists [($318.44/hr + $226.86/hr + $232.88/hr + $284.82/hr + $190.80/hr + $222.60/hr + $294.44/hr + $240.16/hr + $279.14/hr + $286.34/hr + $283.20/hr) ÷ 11].
TABLE 1: National Occupational Employment and Wage Estimates
Occupation Title |
Occupational Code |
Mean Hourly Wage ($/hr.) |
Fringe Benefits and Overhead costs ($/hr) |
Adjusted Hourly Wage ($/hr) |
Anesthesiologists |
29-1211 |
145.66 |
145.66 |
291.32 |
Billing and Posting Clerks |
43-3021 |
21.54 |
21.54 |
43.08 |
Computer Systems Analysts |
15-1211 |
51.70 |
51.70 |
103.40 |
Family Medicine Physicians |
29-1215 |
107.91 |
107.91 |
215.82 |
General Internal Medicine Physicians |
29-1216 |
108.30 |
108.30 |
216.60 |
Licensed Practical Nurse (LPN) |
29-2061 |
26.86 |
26.86 |
53.72 |
Medical and Health Services Managers |
11-9111 |
61.53 |
61.53 |
123.06 |
Obstetricians and Gynecologists |
29-1218 |
133.33 |
133.33 |
266.66 |
Orthopedic Surgeons, Except Pediatric |
29-1242 |
178.56 |
178.56 |
357.12 |
Pediatricians, General |
29-1221 |
97.71 |
97.71 |
195.42 |
Pediatric Surgeons |
29-1243 |
174.51 |
174.51 |
349.02 |
Physicians, All Other |
29-1228 |
114.76 |
114.76 |
229.52 |
Psychiatrists |
29-1223 |
118.92 |
118.92 |
237.84 |
Secretaries and Administrative Assistants |
43-6014 |
20.87 |
20.87 |
41.74 |
Surgeons, All Other |
29-1249 |
167.25 |
167.25 |
334.50 |
Surgeons, Except Ophthalmologists |
29-1240 |
162.49 |
162.49 |
324.98 |
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 Table 2, MIPS eligible clinicians and other clinicians voluntarily submitting data to MIPS may submit data as individuals, groups, 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. Beginning with the CY 2023 performance period/2025 MIPS payment year, clinicians could also participate as subgroups for reporting measures and activities in an MVP. The subgroup reporting option is not available for clinicians participating in traditional MIPS. We finalized in the CY 2022 PFS final rule that a subgroup reporting measures and activities in an MVP will submit its affiliated group’s data for the Promoting Interoperability performance category, and in the scenario that a subgroup does not submit its affiliated group’s data, the subgroup will receive a zero score for the Promoting Interoperability performance category (86 FR 65413 through 65414). 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. We previously finalized in the CY 2021 PFS final rule, for clinicians in APM Entities, the APM Performance Pathway (APP) is available for both ACO and non ACOs to submit quality data (85 FR 84859 through 84866). Due to data limitations and our inability to determine who would use the APP versus the traditional MIPS submission mechanism for the CY 2024 performance period/2026 MIPS payment year, we assume ACO APM Entities will submit data through the APP 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 also want to note that as finalized in the CY 2022 PFS final rule (86 FR 65259 through 65263), the CMS Web Interface collection type is available through the CY 2024 performance period/2026 MIPS payment year only for clinicians participating in the Shared Savings Program. Per section 1899(c) of the Act, submissions received from eligible clinicians in ACOs 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.
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. Additionally, we finalized the introduction of a voluntary reporting option for APM Entities to report the Promoting Interoperability performance category at the APM Entity level beginning with the CY 2023 performance period/2025 MIPS payment year (87 FR 70087 and 70088). Certain MIPS eligible clinicians are automatically eligible for a zero percent weighting for the Promoting Interoperability performance category. Additionally, clinicians who submit an exception application and qualify for significant hardship or other exceptions are also eligible for a zero percent weighting of one or more of the applicable MIPS performance categories.
For the improvement activities performance category, we will assume no reporting burden for MIPS APM participants because we assume they will be reporting through the APM Performance Pathway. In the CY 2017 Quality Payment Program final rule, we established 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 or Organizations Submitting MIPS Data on Behalf of Clinicians, by Type of Data and Category of Clinician
Type of Data Submitted |
Category of Clinician |
Quality Performance Category |
Individual clinician (MIPS eligible, voluntary, opt-in), group, virtual group, subgroup, or APM Entity. Subgroup reporting is only available for clinicians participating in MVP reporting. |
Promoting Interoperability Performance Category |
Individual clinician (MIPS eligible, voluntary, opt-in), group, virtual group, subgroup, or APM Entity. Each eligible clinician in an APM Entity could report data for the Promoting Interoperability performance category at the individual level, or as part of their group TIN, or under their APM Entity TIN. The burden estimates for this final rule assume group TIN-level reporting. |
Improvement Activities Performance Category |
Individual clinician (MIPS eligible, voluntary, opt-in), group, virtual group, subgroup, or APM Entity. 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 (§ 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. |
Reweighting Applications for extreme and uncontrollable circumstances and significant hardship or other exceptions |
Clinicians who submit an application may be eligible for a reweighting of the approved performance category to zero percent under specific circumstances as set forth in §414.1380(c)(2), including, but not limited to, extreme and uncontrollable circumstances and significant hardship or another type of exception. Certain types of MIPS eligible clinicians are automatically eligible for a zero percent weighting for the Promoting Interoperability performance category as described in § 414.1380(c)(2)(i)(A)(4). |
MVP and Subgroup Registration |
An MVP participant, as described at § 414.1305, electing to submit data for the measures and activities in an MVP must register. Clinicians who choose to participate as a subgroup for reporting an MVP must also register. |
Partial QP Election |
Eligible clinicians who attain Partial QP status and choose to participate in MIPS would need to submit a partial QP election form. |
Registration for the CAHPS for MIPS Survey |
Groups electing to use a CMS-approved survey vendor to administer the CAHPS for MIPS survey must register. |
Virtual Group Registration |
Virtual groups must register via email. Virtual group participation is limited to MIPS eligible clinicians, specifically, solo practitioners and groups consisting of 10 eligible clinicians or fewer. |
APM Performance Pathway |
Clinicians in MIPS APMs electing the APM Performance Pathway. The burden estimates for this final rule assume that ACO APM Entities will submit data through the APM Performance Pathway, using the CMS Web Interface option (available through the CY 2024 performance period/2026 MIPS payment year), and non-ACO APM Entities will participate through traditional MIPS, thereby submitting as an individual or group rather than as an APM Entity. |
The policies finalized in the CY 2017 and CY 2018 Quality Payment Program final rules (81 FR 77008 and 82 FR 53568) and CY 2019, 2020, 2021, 2022, and 2023 PFS final rules (83 FR 59452, 84 FR 62568, 85 FR 84472, 86 FR 64996, and 87 FR 70131), and continued in the CY 2024 PFS final 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
Third party intermediary plan audits
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 improvement activities
Call for new Promoting Interoperability measures
Nomination of MVPs
Opt out of performance data display on Compare Tools 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. We note that health IT vendors are not included in the burden estimates for MIPS. Entities seeking approval to submit data on behalf of clinicians as a qualified registry or a QCDR must complete a self-nomination process annually. 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 Self-Nomination Form is submitted electronically using a web-based tool. 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.
We are requesting to add two new ICRs, “simplified qualified registry self-nomination process” and “simplified QCDR self-nomination process”, to represent the estimated burden for the third-party intermediaries submitting applications for the self-nomination process. We discuss the details of these changes in the below sections.
Qualified registries and QCDRs must comply with requirements on the submission of MIPS data to CMS. The burden associated with qualified registry and QCDR data submission requirements will be the time and effort associated with calculating quality measure results from the data submitted to the qualified registry and 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 qualified registry or a QCDR 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 and QCDRs already perform many of these activities for their participants. Therefore, we believe the estimates shown in Tables 3,4,5, and 6 represents the upper bound for qualified registry and QCDR burden, with the potential for less additional MIPS burden if the qualified registry or the QCDR already provides similar data submission services.
The burden associated with qualified registry self-nomination and QCDR self-nomination and measure submission follow:
We are separating the estimated burden for the number of qualified registry self-nomination applications submitted for the simplified and full self-nomination process for the CY 2024 performance period/2026 MIPS payment year. In the CY 2023 PFS final rule (87 FR 70139 through 70140), we used the same estimate for the number of respondents that submitted applications for the simplified and full self-nomination process because we did not have separate estimates at the time. Additionally, we only used the burden for the full qualified registry self-nomination process in our final burden summary estimates. Due to the availability of updated data and the distinct number of estimated respondents for the simplified and full qualified registry self-nomination process, we are requesting to add a new ICR to capture the burden for the simplified qualified registry self-nomination process. We note that the change is not due to policy proposals in the CY 2024 PFS final rule. With the addition of a new ICR, we believe that we would be able to accurately represent the estimated burden incurred by the qualified registries for both the simplified and full self-nomination processes.
Previously approved qualified registries in good standing (i.e., that are not on remedial action or have been terminated) 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.
Based on the number of applications received under the simplified process during the 2023 self-nomination period, we estimate that 84 qualified registries will submit an application under the simplified qualified registry self-nomination process for the CY 2024 performance period/2026 MIPS payment year. We estimate that it would take 0.5 hours to submit an application for the simplified qualified registry self-nomination process. We assume that the staff involved in the simplified qualified registry self-nomination process will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr. We estimate the burden per response would be $51.70 (0.5 hr x $103.40/hr). In aggregate, as shown in Table 3, we estimate that the annual burden for the simplified qualified registry self-nomination process would be 42 hours (84 applications x 0.5hr) at a cost of $4,343 (84 applications x $51.70/application).
TABLE 3: Estimated Burden for Simplified Qualified Registry Self-Nomination
Burden and Respondent Descriptions |
Burden Estimate |
# of Qualified Registry Self-Nomination Applications submitted (a) |
84 |
# of Hours per Qualified Registry Self-Nomination (b) |
0.5 |
Total Annual Hours for Simplified Self-nomination (c) = (a) [x] (b) |
42 |
Cost Per Application (@ computer systems analyst’s labor rate of $103.40/hr) (d) = (b) [x] $103.40/hr |
$51.70 |
Total Annual Cost (e) = (a) [x] (d) |
$4,343 |
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). The self-nomination period is from July 1 to September 1 of the calendar year prior to the applicable performance period.
Based on the number of applications recived under the full process during the 2023 self-nomination period, we estimate that 27 qualified registries will self-nominate under the full qualified registry self-nomination process for the CY 2024 performance period/2026 MIPS payment year.We estimate that it would take 2 hours to submit an application for the full qualified registry self-nomination process. We assume that the staff involved in the full qualified registry self-nomination process will continue to be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr. We estimate the burden per response would be $206.80 (2 hr x $103.40/hr). In aggregate, as shown in Table 4, we estimate that the annual burden for the full qualified registry self-nomination process would be 54 hours (27 applications x 2 hr) at a cost of $5,584 (27 applications x $206.80/application).
TABLE 4: Estimated Burden for Full Qualified Registry Self-Nomination
Burden and Respondent Descriptions |
Burden Estimate |
# of Qualified Registry Self-Nomination Applications submitted (a) |
27 |
# of Hours per Qualified Registry Self-Nomination (b) |
2 |
Total Annual Hours for Full Self-nomination (c) = (a) [x] (b) |
54 |
Cost Per Application (@ computer systems analyst’s labor rate of $103.40/hr) (d) = (b) [x] $103.40/hr |
$206.80 |
Total Annual Cost (e) = (a) [x] (d) |
$5,584 |
Previously approved QCDRs in good standing (that are not on remedial action or have been terminated) that wish to self-nominate under 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).
We are separating the estimated burden for the number of QCDR self-nomination applications submitted for the simplified and full self-nomination process for the CY 2024 performance period/2026 MIPS payment year. In the CY 2023 PFS final rule (87 FR 70137 through 70139), we used the same estimate for the number of respondents that submitted applications under the simplified and full QCDR self-nomination process because we did not have separate estimates at the time. Additionally, we only used the burden for the full QCDR self-nomination process in our final burden summary estimates. Due to the availability of updated data and the distinct number of estimated respondents for the simplified and full self-nomination process, we are requesting to add a new ICR to capture the burden for the simplified QCDR self-nomination process. We note that the change in estimated burden is not due to policy proposals in the CY 2024 PFS final rule. In order to accurately represent the estimated burden incurred by the QCDRs for the simplified and full self-nomination process, we discuss the burden under separate ICRs.
Based on the number of applications received under the simplified process during the 2023 self-nomination period, we estimate that 44 QCDRs will self-nominate under the simplified QCDR self-nomination process for the CY 2024 performance period/2026 MIPS payment year. We estimate that it will take 0.5 hours for a QCDR to submit an application under the simplified self-nomination process. Additionally, we estimate that each QCDR will submit 12 measures on average, approximately 2 new measures and 10 existing or borrowed measures, per QCDR.We estimate that it will take 2 hours for a QCDR to submit a new measure and 0.5 hours to submit an existing measure. Therefore, we estimate the weighted average time required for each QCDR to submit a measure will be 0.75 hours [((2 new measure × 2 hr) + (10 existing or borrowed measures × 0.5 hr))/total # of measures (12)]. In aggregate, we estimate that it will take 9.5 hours [0.5 hr for the simplified self- nomination process + 9 hours for QCDR measure submission (12 measures × 0.75 hr/measure)] for a QCDR to submit an application under the simplified self-nomination process. We assume that the staff involved in the simplified QCDR self-nomination process will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr. We estimate the burden per response would be $982.30 (9.5 hr x $103.40/hr). In aggregate, as shown in Table 5, we estimate that the annual burden for the simplified QCDR self-nomination process would be 418 hours (44 applications x 9.5 hr) at a cost of $43,221 (44 applications x $982.30/application).
TABLE 5: Estimated Burden for Simplified QCDR Self-Nomination
Burden and Respondent Descriptions |
Burden Estimate |
# of QCDR Self-Nomination Applications submitted (a) |
44 |
# of Hours per QCDR Self-Nomination (b) |
9.5 |
Total Annual Hours for Simplified Self-nomination (c) = (a) [x] (b) |
418 |
Cost Per Application (@ computer systems analyst’s labor rate of $103.40/hr) (d) = (b) [x] $103.40/hr |
$982.30 |
Total Annual Cost (e) = (a) [x] (d) |
$43,221 |
New QCDRs 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). The self-nomination period is from July 1 to September 1 of the calendar year prior to the applicable performance period.
Based on the number of applications submitted under the full QCDR self-nomiation process during the 2023 self-nomination period, we estimate that 12 QCDRs will self-nominate under the full QCDR self-nomination process for the CY 2024 performance period/2026 MIPS payment year. We estimate that it will take 2.5 hours for a QCDR to submit an application under the full self-nomination process. Additionally, we estimate that each QCDR will submit 12 measures on average, approximately 2 new measures and 10 existing or borrowed measures, per QCDR.We estimate that it will take 2 hours for a QCDR to submit a new measure and 0.5 hours to submit an existing measure. Therefore, we estimate the weighted average time required for each QCDR to submit a measure will be 0.75 hours [((2 new measure × 2 hr) + (10 existing or borrowed measures × 0.5 hr))/total # of measures (12)]. In aggregate, we estimate that it will take 11.5 hours [2.5 hours for the full self- nomination process + 9 hours for QCDR measure submission (12 measures × 0.75 hr/measure)] for a QCDR to submit an application under the full self-nomination process. We assume that the staff involved in the full QCDR self-nomination process will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr. We estimate the burden per response would be $1,189.10 (11.5 hr x $103.40/hr). In aggregate, as shown in Table 6, we estimate that the annual burden for the full QCDR self-nomination process will be 138 hours (12 applications x 11.5 hr) at a cost of $14,269 (12 applications x $1,189.10/application).
TABLE 6: Estimated Burden for Full QCDR Self-Nomination
Burden and Respondent Descriptions |
Burden Estimate |
# of QCDR Self-Nomination Applications submitted (a) |
12 |
# of Hours per QCDR Self-Nomination (b) |
11.5 |
Total Annual Hours for Full Self-nomination (c) = (a) [x] (b) |
138 |
Cost Per Application (@ computer systems analyst’s labor rate of $103.40/hr) (d) = (b) [x] $103.40/hr |
$1,189.10 |
Total Annual Cost (e) = (a) [x] (d) |
$14,269 |
Targeted Audits
In the CY 2022 PFS final rule (86 FR 65547 through 65548), we finalized that beginning with the CY 2021 performance period/2023 MIPS payment year, the QCDR or qualified registry must conduct targeted audits in accordance with requirements at § 414.1400(b)(3)(vi). For the CY 2024 performance period/2026 MIPS payment year, we estimate that the time required for a QCDR or qualified registry to submit a targeted audit ranges between 5 and 10 hours under the simplified and full self-nomination process, respectively. We assume that the staff involved in submitting the targeted audits will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr.
We estimate that 29 third party intermediaries will submit targeted audits for the CY 2024 performance period/2026 MIPS payment year. We estimate the time required for a QCDR or qualified registry to submit a targeted audit ranges between 5 and 10 hours under the simplified and full self-nomination process, respectively and that the cost for a QCDR or a qualified registry to submit a targeted audit will range from $517 (5 hr x $103.40/hr) to $1,034 (10 hr x $103.40/hr). In aggregate, we estimate the total impact associated with QCDRs and qualified registries completing targeted audits will range from 145 hours (29 responses × 5 hours/audit) at a cost of $14,993 (29 responses × $517/audit) to 290 hours (29 responses × 10 hours/audit) at a cost of $29,986 (29 responses × $1,034/audit) under the simplified and full self-nomination process, respectively (See Tables 7 and 8).
Participation Plans
In the CY 2022 PFS final rule (86 FR 65546), we finalized requirements for approved QCDRs and qualified registries that have not submitted performance data to submit a participation plan as part of their self-nomination process. For the CY 2024 performance period/2026 MIPS payment year, we estimate that it will take 2 hours for a QCDR or qualified registry to submit a participation plan during the self-nomination process. We assume that the staff involved in submitting a participation plan will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr.
We estimate that 64 third party intermediaries will submit participation plans for the CY 2024 performance period/2026 MIPS payment year. We estimate that the cost for a QCDR or a qualified registry to submit a participation plan is $206.80 (2 hours x $103.40/hr). In aggregate, we estimate the total impact associated with QCDRs and qualified registries to submit participation plans will be 128 hours (64 participation plans × 2 hours/plan) at a cost of $13,235 (64 participation plans × $206.80/plan) (See Tables 7 and 8).
Corrective Action Plans (CAPs)
We estimate that 24 third party intermediaries will submit CAPs for the CY 2024 performance period/2026 MIPS payment year. Additionally, we estimate that it will take 3 hours for a QCDR or qualified registry to submit a CAP. We assume that the staff involved in submitting the CAPs will be computer systems analysts or their equivalent, who have an average labor rate of $103.40/hr. We estimate that the cost for a QCDR or a qualified registry to submit a CAP is $310.20 (3 hours x $103.40/hr). In aggregate, we estimate the total impact associated with QCDRs and qualified registries to CAPs would be 72 hours (24 CAPs × 3 hours/response) at a cost of $7,445 (24 CAPs × $310.20/response) (See Tables 7 and 8).
Transition Plans
In the CY 2020 PFS final rule (84 FR 63052 through 63053), we established a policy at § 414.1400(a)(4)(vi) that a condition of approval for the third party intermediary is to agree that prior to discontinuing services to any MIPS eligible clinician, group or virtual group during a performance period, the third party intermediary must support the transition of such MIPS eligible clinician, group, or virtual group to an alternate third party intermediary, submitter type, or, for any measure on which data has been collected, collection type according to a CMS approved transition plan.
We estimate that we will receive 9 transition plans from QCDRs and qualified registries for the CY 2024 performance period/2026 MIPS payment year. We estimate that it will take 1 hour for a computer system analyst or their equivalent at a labor rate of $103.40/hr to develop a transition plan on behalf of each QCDR or qualified registry during the self-nomination period. However, we are unable to estimate the burden for implementing the actions in the transition plan because the level of effort may vary for each QCDR or qualified registry. Therefore, we estimate the total impact associated with qualified registries completing transition plans is 9 hours (9 transition plans × 1 hour/plan) at a cost of $931 (9 transition plans × $103.40/plan).
In aggregate, as shown in Table 7, we assume that 126 third party intermediaries will submit plan audits (29 targeted audits, 64 participation plans, 24 CAPs, and 9 transition plans).
TABLE 7: Estimated Number of Respondents to Submit Plan Audits
Burden and Respondent Descriptions |
# of Respondents |
# of Targeted Audits (a) |
29 |
# of Participation Plans (b) |
64 |
# of Corrective Action Plans (CAPs) (c) |
24 |
# of Transition Plans (d) |
9 |
Total Respondents (e) = (a) + (b) + (c) + (d) |
126 |
As shown in Table 8, for the CY 2024 performance period/2026 MIPS payment year, in aggregate, the estimated annual burden to submit plan audits under the simplified and full self-nomination process will range from 354 hours to 499 hours at a cost ranging from $36,604 (354 hr x $103.40 /hr) and $51,597 (499 hr x $103.40 /hr), respectively.
TABLE 8: Estimated Burden for Third Party Intermediary Plan Audits
Burden and Respondent Descriptions |
Simplified Process |
Full Process |
# of Hours per Completion of Targeted Audit (a) |
5 |
10 |
Total Annual Hours for Completion of 29 Targeted Audits (b) |
145 |
290 |
# of Hours per Submission of Participation Plan (c) |
2 |
2 |
Total Annual Hours for Submission of 64 Participation Plans (d) |
128 |
128 |
# of Hours per Submission of CAP (e) |
3 |
3 |
Total Annual Hours for Submission of 24 CAPs (f) |
72 |
72 |
# of Hours per Submission of Transition Plan (g) |
1 |
1 |
Total Annual Hours for Submission of 9 Transition Plans (h) |
9 |
9 |
Total Annual Hours for Submission of Plan Audits (i) = (b) + (d) + (f) + (h) |
354 |
499 |
Cost Per Targeted Audit (@ computer systems analyst’s labor rate of $103.40/hr) (j) = (a) [x] $103.40/hr |
$517 |
$1,034 |
Cost Per Participation Plan (@ computer systems analyst’s labor rate of $103.40/hr) (k) = (c) [x] $103.40/hr |
$206.80 |
$206.80 |
Cost per CAP (@ computer systems analyst’s labor rate of $103.40/hr) (l) = (e) [x] $103.40/hr |
$310.20 |
$310.20 |
Cost per Transition Plan @computer systems analyst’s labor rate of $103.40/hr (m) = (g) [x] $103.40/hr |
$103.40 |
$103.40 |
Total Annual Cost (n) = 29 [x] (j) + 64 [x] (k) + 24 [x] (l) + 9 [x] (m) (simplified) and 29 [x] (j) + 64 [x] (k) + 24 [x] (l) + 9 [x] (m) (full) |
$36,604 |
$51,597 |
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.
As shown in Table 9, we estimate that we will receive 15 requests to complete this process for the CY 2024 performance period/2026 MIPS payment year. We estimate that it would take 2 hours at $103.40/hr for a computer systems analyst (or their equivalent) to complete the process, resulting in an estimated cost of $206.80 (2 hours x $103.40/hr) per response. In aggregate, we estimate an annual burden of 30 hours (15 vendors x 2 hrs) at a cost of $3,102 (15 requests x $206.80/request).
TABLE 9: 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) |
2 |
Total Annual Hours (c) = (a) [x] (b) |
30 |
Cost Per Organization (@ computer systems analyst’s labor rate of $103.40/hr.) (d) = (b) [x] $103.40/hr |
$206.80 |
Total Annual Cost (e) = (a) [x] (d) |
$3,102 |
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 third snapshot date for the CY 2022 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 CY 2024 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 2024 performance period/2026 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.
The burden associated with the submission of quality performance category data has 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 CEHRT 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, QCDR, and eCQM collection types, we also assume that, on average, each clinician or group will submit 6 quality measures. Additionally, we capture the burden for clinicians who choose to submit via these collection types for the quality performance category of MVPs. We finalized in the CY 2022 PFS final rule (86 FR 65411 through 65412) 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.
As shown in Table 10, we estimate that 6,500 respondents will submit their information to obtain new user accounts in the HARP system for the CY 2024 performance period/2026 MIPS payment year. We estimate that it would take 1 hour at $103.40/hr for a computer systems analyst (or their equivalent) to obtain an account for the HARP system, resulting in an estimated cost of $103.40 per application. In aggregate we estimate an annual burden of 6,500 hours (6,500 applications x 1 hr/registration) at a cost of $672,100 (6,500 applications x $103.40/application).
TABLE 10: 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) |
6,500 |
Total Hours Per Application (b) |
1 |
Total Annual Hours for completing the Identity Management Application Process (c) = (a) [x] (b) |
6,500 |
Cost Per Application @ computer systems analyst’s labor rate of $103.40/hr.) (d) = (b) [x] $103.40/hr |
$103.40 |
Total Annual Cost for completing the Identity Management Application Process (e) = (a) [x] (d) |
$672,100 |
As noted in Table 11, based on CY 2022 performance period/2024 MIPS payment year submission data, we assume that 13,413 individual clinicians will collect and submit quality data via the Medicare Part B claims collection type.
As shown in Table 11, 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 $15.51 (0.15 hr x $103.40/hr) to 7.2 hours at a cost of $744.48 (7.2 hr x $103.40/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 $123.06/hr for a medical and health services manager, 1 hour at $274.44/hr for a physician, 1 hour at $53.72/hr for an LPN, 1 hour at $103.40/hr for a computer systems analyst, and 1 hour at $43.08/hr for a billing and posting clerk.
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.
As shown in Table 11, for the CY 2024 performance period/2026 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 aggregate, the total annual time ranges from 95,903 hours (7.15 hr x 13,413 clinicians) to 190,465 hours (14.2 hr x 13,413 clinicians). The estimated annual cost (per clinician) ranges from $859.33 [(0.15 hr x $103.40/hr) + (3 hr x $123.06/hr) + (1 hr x $103.40/hr) + (1 hr x $53.72/hr) + (1 hr x $43.06/hr) + (1 hr x $274.44/hr)] to a maximum of $1,588.30 [(7.2 hr x $103.40/hr) + (3 hr x $123.06/hr) + (1 hr x $103.40/hr) + (1 hr x $53.72/hr) + (1 hr x $43.06/hr) + (1 hr x $274.44/hr)]. The total annual cost for the CY 2024 performance period/2026 MIPS payment year ranges from a minimum of $11,526,193 (13,413 clinicians x $859.33) to a maximum of $21,303,868 (13,413 clinicians x $1,588.30).
TABLE 11: 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 |
# of Clinicians (a) |
13,413 |
13,413 |
13,413 |
Hours Per Clinician to Submit Quality Data (b) |
0.15 |
1.05 |
7.2 |
# of Hours Medical and health services manager Review Measure Specifications (c) |
3 |
3 |
3 |
# of Hours Computer Systems Analyst Review Measure Specifications (d) |
1 |
1 |
1 |
# of Hours LPN Review Measure Specifications (e) |
1 |
1 |
1 |
# of Hours Billing Clerk Review Measure Specifications (f) |
1 |
1 |
1 |
# of Hours Clinician Review Measure Specifications (g) |
1 |
1 |
1 |
Annual Hours per Clinician (h) = (b)+(c)+(d)+(e)+(f)+(g) |
7.15 |
8.05 |
14.2 |
Total Annual Hours (i) = (a) [x] (h) |
95,903 |
107,975 |
190,465 |
Cost to Submit Quality Data (@ computer systems analyst’s labor rate of $103.40/hr @ varying times) (j) |
$15.51 |
$108.57 |
$744.48 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $123.06/hr @ 3 hr) (k) |
$369.18 |
$369.18 |
$369.18 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $103.40/hr @ 1 hr) (l) |
$103.40 |
$103.40 |
$103.40 |
Cost to Review Measure Specifications (@ LPN's labor rate of $53.72/hr @1 hr) (m) |
$53.72 |
$53.72 |
$53.72 |
Cost to Review Measure Specifications (@ billing clerk’s labor rate of $43.08/hr @ 1 hr) (n) |
$43.08 |
$43.08 |
$43.08 |
Cost to Review Measure Specifications (@ physician’s labor rate of $274.44/hr @ 1 hr) (o) |
$274.44 |
$274.44 |
$274.44 |
Total Annual Cost Per Clinician (p) = (j)+(k)+(l)+(m)+(n)+(o) |
$859.33 |
$952.39 |
$1,588.30 |
Total Annual Cost (q) = (a) [x] (p) |
$11,526,193 |
$12,774,407 |
$21,303,868 |
Based on CY 2022 performance period/2024 MIPS payment year submission data, for the CY 2024 performance period/2026 MIPS payment year, we estimate that 16,632 clinicians (10,682 individual clinicians and 5,950 groups and virtual groups) will submit quality data for the MIPS CQM and 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 collection type, 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 totals 9.083 hours. This consists of 3 hours at $103.40/hr for a computer systems analyst (or their equivalent) to submit quality data along with 2 hours at $123.06/hr for a medical and health services manager, 1 hour at $103.40/hr for a computer systems analyst, 1 hour at $53.72/hr for a LPN, 1 hour at $43.08/hr for a billing clerk, and 1 hour at $274.44/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 $103.40/hr for a computer systems analyst at a cost of $8.58 (0.083 hr x $103.40/hr). Overall, we estimate 9.083 hrs/response (3 hrs + 2 hrs + 1 hr + 1 hr + 1 hr + 1 hr + 0.083 hrs) at a cost of $1,039.54/response [(3 hr x $103.40/hr) + (2 hr x $123.06/hr) + (1 hr x $274.44/hr) + (1 hr x $103.40/hr) + (1 hr x $53.72/hr) + (1 hr x $43.08/hr) + (0.083 hr x $103.40/hr)].
As shown in Table 12, for the CY 2024 performance period/2026 MIPS payment year, in aggregate, we estimate a burden of 151,068 hours [9.083 hr/response x 16,632 responses (10,682 clinicians submitting as individuals + 5,950 groups submitting via QCDR or MIPS CQM on behalf of individual clinicians)] at a cost of $17,289,629 (16,632 responses x $1,039.54/response).
TABLE 12: 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 |
Burden Estimate |
# of clinicians submitting as individuals (a) |
10,682 |
# of groups submitting via QCDR or MIPS CQM on behalf of individual clinicians (b) |
5,950 |
# of Respondents (groups and clinicians submitting as individuals) (c)=(a)+(b) |
16,632 |
Hours Per Respondent to Report Quality Data (d) |
3 |
# of Hours Medical and health services manager Review Measure Specifications (e) |
2 |
# of Hours Computer Systems Analyst Review Measure Specifications (f) |
1 |
# of Hours LPN Review Measure Specifications (g) |
1 |
# of Hours Billing Clerk Review Measure Specifications (h) |
1 |
# of Hours Clinician Review Measure Specifications (i) |
1 |
# of Hours Per Respondent to Authorize Qualified Registry to Report on Respondent's Behalf (j) |
0.083 |
Annual Hours Per Respondent (k)= (d)+(e)+(f)+(g)+(h)+(i)+(j) |
9.083 |
Total Annual Hours (l) = (c) [x] (k) |
151,068 |
Cost Per Respondent to Submit Quality Data (@ computer systems analyst’s labor rate of $103.40/hr) (m) |
$310.20 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $123.06/hr) (n) |
$246.12 |
Cost for Computer System Analyst to Review Measure Specifications (@ computer systems analyst’s labor rate of $103.40/hr) (o) |
$103.40 |
Cost for LPN to Review Measure Specifications (@ LPN's labor rate of $53.72/hr) (p) |
$53.72 |
Cost for Billing Clerk to Review Measure Specifications (@ clerk’s labor rate of $43.08/hr) (q) |
$43.08 |
Cost for Physician to Review Measure Specifications (@ physician’s labor rate of $274.44/hr) (r) |
$274.44 |
Cost for Respondent to Authorize Qualified Registry/QCDR to Report on Respondent's Behalf (@ computer systems analyst’s labor rate of $103.40/hr) (s) |
$8.58 |
Total Annual Cost Per Respondent (t) = (m)+(n)+(o)+(p)+(q)+(r)+(s) |
$1,039.54 |
Total Annual Cost (u) = (c) [x] (t) |
$17,289,629 |
As noted in Table 13 below, based on submission data in the CY 2022 performance period/2024 MIPS payment year, we estimate that 28,714 clinicians (22,897 individual clinicians and 5,817 groups and virtual groups) will submit quality data using the eCQM collection type for the CY 2024 performance period/2026 MIPS payment year. 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 $103.40/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 $123.06/hr for a medical and health services manager, 1 hour at $274.44/hr for a physician, 1 hour at $103.40/hr for a computer systems analyst, 1 hour at $53.72/hr for an LPN, and 1 hour at $43.08/hr for a billing clerk. As shown in Table 13, we estimate a cost of $927.56/response [(2 hr x $103.40/hr) + (2 hr x $123.06/hr) + (1 hr x $274.44/hr) + (1 hr x $103.40/hr) + (1 hr x $53.72/hr) + (1 hr x $43.08/hr)].
As shown in Table 13, for the CY 2024 performance period/2026 MIPS payment year, we estimate a burden of 229,712 hours [8 hr x 28,714 (5,817 groups and 22,897 clinicians submitting as individuals)] at a cost of $26,633,958 (28,714 responses x $927.56/response).
TABLE 13: Estimated Burden for Quality Performance Category:
Clinicians
(Submitting Individually or as Part of a Group)
Using the eCQM Collection Type
Burden and Respondent Descriptions |
Burden estimate |
# of Clinicians submitting as individuals (a) |
22,897 |
# of Groups submitting via EHR on behalf of individual clinicians (b) |
5,817 |
# of Respondents (groups and clinicians submitting as individuals) (c)=(a)+(b) |
28,714 |
# of Hours Per Respondent to Submit MIPS Quality Data File to CMS (d) |
2 |
# of Hours Medical and health services manager Review Measure Specifications (e) |
2 |
# of Hours Computer Systems Analyst Review Measure Specifications (f) |
1 |
# of Hours LPN Review Measure Specifications (g) |
1 |
# of Hours Billing Clerk Review Measure Specifications (h) |
1 |
# of Hours Clinicians Review Measure Specifications (i) |
1 |
Annual Hours Per Respondent (j)=(d)+(e)+(f)+(g)+(h)+(i) |
8 |
Total Annual Hours (k)=(c) [x] (j) |
229,712 |
Cost Per Respondent to Submit Quality Data (@ computer systems analyst’s labor rate of $103.40/hr) (l) |
$206.80 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $123.06/hr) (m) |
$246.12 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $103.40/hr) (n) |
$103.40 |
Cost to Review Measure Specifications (@ LPN's labor rate of $53.72/hr) (o) |
$53.72 |
Cost to Review Measure Specifications (@ clerk’s labor rate of $43.08/hr) (p) |
$43.08 |
Cost to Review Measure Specifications (@ physician’s labor rate of $274.44/hr) (q) |
$274.44 |
Total Cost Per Respondent (r)=(l)+(m)+(n)+(o)+(p)+(q) |
$927.56 |
Total Annual Cost (s) = (c) [x] (r) |
$26,633,958 |
In the CY 2022 PFS final rule, we finalized the implementation of voluntary MIPS Value Pathways (MVP) and subgroup reporting for eligible clinicians beginning with the CY 2023 performance period/2025 MIPS payment year. Therefore, clinicians participating in MIPS will have the option to voluntarily submit data using MVPs starting with the CY 2023 performance period/2025 MIPS payment year. Additionally, clinicians participating in MIPS through reporting MVPs could also choose to form subgroups beginning with the CY 2023 performance period/2025 MIPS payment year. The MVPs will 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 will 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 ICRs reflect the burden associated with data collection related to the implementation of MVPs and subgroup reporting in the CY 2024 performance period/2026 MIPS payment year.
For the ICRs related to MVP participants, our burden estimates are based on the MIPS submission data from the CY 2022 performance period/2024 MIPS payment year. In Appendix 3: MVP Inventory of the CY 2024 PFS final rule, we are finalizing to add five new MVPs to the MVP Inventory. Additionally, we are finalizing to consolidate the previously finalized Promoting Wellness and Optimizing Chronic Disease Management MVPs into a single consolidated primary care MVP titled Value in Primary Care MVP. Therefore, MVP participants will have a total of sixteen MVPs available for the CY 2024 performance period/2026 MIPS payment year. Due to the availability of new MVPs, we expect an increase in the projected number of MVP participants. For each newly finalized MVP, we calculated the average quality measure submission rate across the measures available in each MVP for the CY 2022 performance period/2024 MIPS payment year. The total of these average quality measure submissions for each MVP was equivalent to about 2 percent of total quality measure submissions in the CY 2022 performance period/2024 MIPS payment year. Therefore, we estimate that 14 percent of the clinicians will participate in MVP reporting in the CY 2024 performance period/2026 MIPS payment year.
Beginning with the CY 2024 performance period/2026 MIPS payment year, clinicians interested in participating in MIPS through MVP reporting would be required to complete an annual registration process described in the CY 2022 PFS final rule (86 FR 65589 through 65590). 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 14 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. 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 $103.40/hour.
Based on submission data from the CY 2022 performance period/2024 MIPS payment year, and accounting for the finalized changes to the existing MVPs and the finalized addition of 5 new MVPs, we estimate that 14 percent of the clinicians that currently participate in MIPS will submit data for the measures and activities in an MVP. For the CY 2024 performance period/2026 MIPS payment year, we assume that a total of 9,585 submissions will 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 estimate that the total number of individual clinicians, groups, subgroups and APM Entities to complete the MVP registration process is 9,585 As shown in Table 14, we estimate that it will take 2,396 hours (9,585 registrations x 0.25 hr/registration) for individual clinicians, groups, subgroups, and APM Entities to complete the MVP registration process at a cost of $247,772 (9,585 registrations x $25.85/registration) for the CY 2024 performance period/2026 MIPS payment year.
TABLE 14: 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) |
9,585 |
Estimated Total Annual Burden Hours Per Registration (b) |
0.25 |
Estimated Total Annual Burden Hours for MVP Registration (c) = (a) [x] (b) |
2,396 |
Estimated Cost Per MVP (@ computer systems analyst’s labor rate of $103.40/hr. (d) = (b) [x] $103.40/hr |
$25.85 |
Estimated Total Annual Burden Cost for MVP Registration (e) = (a) [x] (d) |
$247,772 |
In the CY 2022 PFS final rule, we finalized 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 12, clinicians who choose to form subgroups for reporting the MVPs will 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 final rule (86 FR 65415 through 65418). For the CY 2024 performance period/2026 MIPS payment year, we estimate that clinicians would choose to form 20 subgroups for reporting the measures and activities in MVPs and that it would require a minimum of 0.5 hours per subgroup respondent to submit the finalized requirements for subgroup registration.
As shown in Table 15 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 $103.40/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 $1,034 (20 subgroups x $51.70/registration).
As subgroup participation option is only available to report MVPs, the burden associated with subgroup reporting of the quality performance category 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 15: Total Estimated Burden for Subgroup Registration
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) [x] (b) |
10 |
Estimated Cost Per Subgroup (@ computer systems analyst’s labor rate of $103.40/hr. (d) = (b) [x] $103.40/hr |
$51.70 |
Estimated Total Annual Burden Cost for Subgroup Registration (e) = (a) [x] (d) |
$1,034 |
In the CY 2022 PFS final rule (86 FR 65411 through 65415), we finalized 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 2023 PFS final 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.
For the CY 2024 performance period/2026 MIPS payment year, we estimate that 14 percent of the clinicians who participated in MIPS for the CY 2022 performance period/2024 MIPS payment year, and 20 subgroups will submit data for the quality performance category of MVPs. As shown in Table 16, we estimate that approximately 4,674 clinicians and 10 subgroups will submit data using eCQMs collection type at a cost of $614.45/response (see line q for eCQMs); 2,707 clinicians and 10 subgroups will submit data using MIPS CQM and QCDR collection type at a cost of $683.73/response (see line q for CQM and QCDRs); and 2,184 clinicians and 0 subgroups will submit data for the MVP quality performance category using the Medicare Part B claims collection type at a cost of $1,055.70/response (see line q for claims).
As shown in Table 16, for the CY 2024 performance period/2026 MIPS payment year, we estimate a burden of 24,825 hours [5.3 hr x 4,684 (4,674 +10) responses] at a cost of $2,878,084 (4,684 responses x $614.45/response) for the eCQM collection type, 16,220 hours [5.97 hr x 2,717 (2,707 +10)] at a cost of $1,857,694 (2,717 responses x $683.73/responses) for the MIPS CQM and QCDR collection type, and 20,617 hours (9.44 hr x 2,184 clinician responses) at a cost of $2,305,649 (2,184 responses x $1,055.70/response) for the Medicare Part B claims collection type.
TABLE 16: Estimated Burden for Quality Performance Category Submission
Burden and Respondent Descriptions |
eCQM Collection Type |
CQM and QCDR Collection Type |
Claims Collection Type |
# of Submissions from pre-existing collection types (a) |
4,674 |
2,707 |
2,184 |
# of Subgroup reporters (b) |
10 |
10 |
0 |
Total MVP participants (c) = (a) + (b) |
4,684 |
2,717 |
2,184 |
Hours Per Clinician to Submit Quality Data (d) |
1.33 |
2 |
4.8 |
# of Hours for Medical and Health Services Manager to Review Measure Specifications (e) |
1.33 |
1.33 |
2 |
# of Hours for Computer Systems Analyst to Review Measure Specifications (f) |
0.66 |
0.66 |
0.66 |
# of Hours for LPN to Review Measure Specifications (g) |
0.66 |
0.66 |
0.66 |
# of Hours for Billing Clerk to Review Measure Specifications (h) |
0.66 |
0.66 |
0.66 |
# of Hours for Physician to 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) [x] (j) |
24,825 |
16,220 |
20,617 |
Cost to Submit Quality Data (@ computer systems analyst’s labor rate of $103.40/hr @ varying times) (k) |
$137.52 |
$206.80 |
$496.32 |
Cost to Review Measure Specifications (@ medical and health services manager's labor rate of $123.06/hr) (l) |
$163.67 |
$163.67 |
$246.12 |
Cost to Review Measure Specifications (@ computer systems analyst’s labor rate of $103.40/hr) (m) |
$68.24 |
$68.24 |
$68.24 |
Cost to Review Measure Specifications (@ LPN's labor rate of $53.72/hr) (n) |
$35.46 |
$35.46 |
$35.46 |
Cost to Review Measure Specifications (@ billing clerk’s labor rate of $43.08/hr) (o) |
$28.43 |
$28.43 |
$28.43 |
Cost to Review Measure Specifications (@ physician’s labor rate of $274.44/hr) (p) |
$181.13 |
$181.13 |
$181.13 |
Total Annual Cost Per Clinician (q) = (k) + (l) + (m) + (n) + (o) + (p) |
$614.45 |
$683.73 |
$1,055.70 |
Total Annual Cost (r) = (c) [x] (q) |
$2,878,084 |
$1,857,694 |
$2,305,649 |
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.
As shown in Table 17, we estimate that we will receive 31 quality measure submissions during the 2023 Annual Call for Quality Measures for the CY 2024 performance period/2026 MIPS payment year. We estimate that it would take approximately 5.5 hours per quality measure submission. This estimate includes 2.4 hours for the practice administrator at $123.06/hr and 1.1 hours at $274.44/hr for a clinician to identify, propose, and link the quality measure, and approximately 2 hours at $274.44/hr for a clinician to complete the Peer Review Journal Article Form.
As shown in Table 17, in aggregate we estimate an annual burden of 171 hours (31 submissions x 5.5 hr/submission) at a cost of $35,529 {31 measure submissions x $1,146.11 [(2.4 hr x $123.06/hr) + (3.1 hr x $274.44/hr)]}.
TABLE 17: Burden Estimates for Call for Quality Measures
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations Nominating New Quality Measures (a) |
31 |
# 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 |
Annual Hours Per Response (e)= (b) + (c) + (d) |
5.5 |
Total Annual Hours (f) = (a) [x] (e) |
171 |
Cost to Identify and Submit Measure (@practice administrator's labor rate of $123.06/hr.) [x] 2.4 hr (g) |
$295.34 |
Cost to Identify Quality Measure and Complete Peer Review Article Form (@ physician’s labor rate of $274.44/hr.) [x] 3.1 hr (h) |
$850.77 |
Total Annual Cost Per Respondent (i) = (g) + (h) |
$1,146.11 |
Total Annual Cost (j) = (a) [x] (i) |
$35,529 |
For the CY 2024 performance period/2026 MIPS payment year, MIPS eligible clinicians and groups, subgroups, and APM Entities 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 18 summarizes the burden for clinicians to apply for reweighting the Promoting Interoperability performance category to zero percent due to a significant hardship exception or because of a decertification of an EHR. Based on the number of reweighting applications received for the CY 2022 performance period/2024 MIPS payment year, we assume that we will receive approximately 29,227 reweighting applications for the CY 2024 performance period/2026 MIPS payment year. Out of the 29,227, we estimate that 2,706 respondents (eligible clinicians or groups) will submit a request to reweight the Promoting Interoperability performance category to zero percent due to a significant hardship or other exception as provided under § 414.1380(c)(2)(i)(C), and that the remaining 26,510 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. Additionally, we estimate that 11 APM Entities will submit an extreme and uncontrollable circumstances exception application for the CY 2024 performance period/2026 MIPS payment year.
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.
As shown in Table 18, we estimate that it will take 0.25 hours at $103.40/hr for a computer system analyst to complete and submit the application. As shown in Table 18, in aggregate, we estimate an annual burden of 7,307 hours (29,227 applications x 0.25 hr/application) at an annual cost of $ 755,518 (29,227 applications x $25.85/application).
TABLE 18: Estimated Burden for Reweighting Applications for Promoting Interoperability and Other Performance Categories
Burden and Respondent Descriptions |
Burden Estimate |
# of Eligible Clinicians or Groups Applying Due to Significant Hardship and Other Exceptions or Extreme and Uncontrollable Circumstances (a) |
29,216 |
# APM Entities requesting Extreme and Uncontrollable Circumstances exception (b) |
11 |
Total Applications Submitted (c) |
29,227 |
Annual Hours Per Applicant per Application Submission (d) |
0.25 |
Total Annual Hours (e) = (c) [x] (d) |
7,307 |
Cost to Submit a Reweighting Application @ computer systems analyst’s labor rate of $103.40/hr (f) = (d) *$103.40/hr |
$25.85 |
Total Annual Cost (g) = (e) [x] (f) |
$755,518 |
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 or a subgroup. 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 19, based on data from the CY 2022 performance period/2024 MIPS payment year, we estimate that a total of 25,990 respondents consisting of 19,292 individual MIPS eligible clinicians, 6,678 groups and virtual groups, and 20 subgroups will submit Promoting Interoperability data for the CY 2024 performance period/2026 MIPS payment year.
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, and clinical social workers. 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.
We assume that MIPS eligible clinicians previously scored under the APM scoring standard, as described in the CY 2020 PFS final rule, will continue to submit Promoting Interoperability data (84 FR 63006) in a similar way through the APP. Each MIPS eligible clinician in an APM Entity reports data for the Promoting Interoperability performance category through either their group TIN or individual reporting. In the CY 2023 PFS final rule, we finalized a a voluntary reporting option for APM Entities to report the Promoting Interoperability performance category at the APM Entity level beginning with the CY 2023 performance period/2025 MIPS payment year. 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 final 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.
We estimate that it will take 2.70 hours of 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) for clinicians to submit data for the Promoting Interoperability performance category. As shown in Table 19, 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 $103.40/hr. In aggregate, the total burden estimate for submitting data on the specified Promoting Interoperability objectives and measures is estimated to be 70,173 hours (25,990 respondents x 2.70 hours) and $7,255,888 (25,990 respondents x $279.18/respondent).
TABLE 19: Estimated Burden for Promoting Interoperability
Performance Category
Data Submission
Burden and Respondent Descriptions |
Burden Estimate |
Number of individual clinicians to submit Promoting Interoperability (a) |
19,292 |
Number of groups to submit Promoting Interoperability (b) |
6,678 |
Number of subgroups to submit Promoting Interoperability (c) |
20 |
Total (d) = (a) + (b) + (c) |
25,990 |
Annual Hours Per Respondent (e) |
2.70 |
Total Annual Hours (f) = (d) [x] (e) |
70,173 |
Cost per respondent at Labor rate for a computer systems analyst @$103.40/hr (g) = (e) [x] $103.40/hr |
$279.18 |
Total Annual Cost (h) = (d) [x] (g) |
$7,255,888 |
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). Due to a consistent decline in the number of submissions received for the Promoting Interoperability performance category measures, we estimate to receive fewer than 10 responses for this ICR. Therefore, we are proposing to remove the ICR for nomination of Promoting Interoperability performance category measures.
As shown in Table 20, we estimate that we will receive zero measures for the CY 2024 performance period/2026 MIPS payment year. We estimate that it will take 0.5 hours per organization to submit an activity to us, consisting of 0.3 hours at $123.06/hr for a medical and health services manager to make a strategic decision to nominate that measure and submit a measure to us via email and 0.2 hours at $274.44/hr for a clinician to review the nomination. As shown in Table 20, we estimate an annual burden of 0 hours (0 nominations x 0.5 hr/response) at a cost of $0 (0 x [(0.3 h x $123.06/hr) + (0.2 hr x $274.44/hr)].
TABLE 20: Estimated Burden for Call for Promoting Interoperability Measures
Burden and Respondent Descriptions |
Burden Estimate |
# of Organizations Nominating New Promoting Interoperability Measures (a) |
0 |
# 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) [x] (d) |
0 |
Cost to Identify and Submit Measure (@ medical and health services manager's labor rate of $123.06/hr.) (f) = (b) [x] $123.06/hr |
$36.92 |
Cost to Identify Measure (@ physician’s labor rate of $274.44/hr.) (g) = (c) [x] $274.44/hr |
$54.89 |
Total Annual Cost Per Respondent (h) = (f) + (g) |
$91.81 |
Total Annual Cost (i) = (a) [x] (h) |
$0 |
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 2024 performance period/2026 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 21, based on CY 2022 performance period/2024 MIPS payment year, we estimate that a total of 50,289 respondents consisting of 37,939 individual clinicians and 12,330 groups, and 20 subgroups will submit improvement activities during the CY 2024 performance period/2026 MIPS payment year.
We estimate that it would take 5 minutes (or 0.083 hours) for a computer system analyst at a labor rate of $103.40/hr 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. As shown in Table 21, we estimate an annual burden of 4,174 hours (50,289 responses x 0.083 hr) at a cost of $431,480 (50,289 respondents x $8.58/respondent) for the CY 2024 performance period/2026 MIPS payment year.
TABLE 21: Estimated Burden for Improvement Activities Submission
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) |
50,289 |
Total Annual Hours Per Respondent (b) |
0.083 |
Total Annual Hours (c) |
4,174 |
Cost per respondent at Labor rate for a computer systems analyst @$103.40/hr (d) = (b) [x] $103.40/hr |
$8.58 |
Total Annual Cost (e) = (a) x (d) |
$431,480 |
Interested parties are provided an opportunity to propose new activities formally via the Annual Call for Activities nomination form posted on the CMS website. For the CY 2024 performance period/2026 MIPS payment year, we estimate that we will receive 15 nominations of new or modified activities which will be evaluated for the Improvement Activities Under Consideration list for possible inclusion in the CY 2024 Improvement Activities Inventory.
As shown in Table 22, we estimate that it would take 2.8 hours at $123.06/hr for a medical and health services manager or equivalent and 1.6 hours at $274.44 /hr for a physician to nominate an improvement activity. In aggregate, we estimate an annual information collection burden of 66 hours (15 nominations x 4.4 hr/nomination) at a cost of $11,755 (15 x [(2.8 hr x $123.06/hr) + (1.6 hr x $274.44/hr)]) for the CY 2024 performance period/2026 MIPS payment year.
TABLE 22: Burden Estimates for Nomination of Improvement Activities
Burden and Respondent Descriptions |
Burden Estimate |
# of Nominations of New IAs (a) |
15 |
# of Hours Per Medical and Health Services Manager (b) |
2.8 |
# of Hours Per Physician (c) |
1.6 |
Annual Hours Per Respondent (d)= (b) + (c) |
4.4 |
Total Annual Hours (e) = (a) * (d) |
66 |
Cost to Nominate an IA (@ medical and health services manager's labor rate of $123.06/hr) (f) = (b) x $123.06/hr |
$344.57 |
Cost to Nominate an IA (@ physician’s labor rate of $274.44/hr) (g) = (c) x $274.44/hr |
$439.10 |
Total Annual Cost Per Respondent (h) = (f) + (g) |
$783.67 |
Total Annual Cost (i) = (a) [x] (h) |
$11,755 |
We have previously established MVP development criteria for interested parties submitting an MVP candidate for inclusion in the MVP Inventory (85 FR 84849 through 84856 and 87 FR 70035 through 70037). As new 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 2024 performance period/2026 MIPS payment year, we estimate that we will receive 10 MVP nominations, and we estimate that the 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 $123.06/hr for a medical and health services manager or equivalent and 4.8 hours at $274.44/hr for a physician to nominate an MVP. As shown in Table 23, we estimate an annual burden of 120 hours (10 nominations x 12 hr/nomination) at a cost of $22,033 (10 x [(7.2 hr x $123.06/hr) + (4.8 hr x $274.44/hr)]).
TABLE 23: Estimated Burden for Nomination of MVPs
Burden and Respondent Descriptions |
Burden Estimate |
# of Nominations of New MVPs (a) |
10 |
# 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) [x] (d) |
120 |
Cost to Nominate an MVP (@ medical and health services manager's labor rate of $123.06/hr) (f) = (b) [x] $123.06/hr |
$886.03 |
Cost to Nominate an MVP (@ physician’s labor rate of $274.44/hr) (g) = (c) [x] $274.44/hr |
$1,317.31 |
Total Annual Cost Per Respondent (h) = (f) + (g) |
$2,203.34 |
Total Annual Cost (i) = (a) [x] (h) |
$22,033 |
The cost performance category relies on administrative claims data. The Medicare claims submission process (OMB control number 0938-1197; CMS-1500 and CMS-1490S and OMB control number 0938-0992) 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 2024 PFS final rule do not result in the need to add or revise or delete any claims data fields. Therefore, we did not implement 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 individual eligible clinician level, the burden of Partial QP election will be incurred by the individual 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 24, based on historical response rates in the CY 2021 performance period/2023 MIPS payment year, we estimate that a total of 287 respondents, 156 APM Entities and 131 individual eligible clinicians (representing approximately 7,182 Partial QPs) will make the election to participate as a Partial QP in MIPS. We estimate it will take the APM Entity representative or eligible clinician 15 minutes (0.25 hr) at a rate of $103.40/hr, resulting in a cost of $25.85, to make this election. In aggregate, we estimate an annual burden of 72 hours (287 partial QP elections x 0.25 hr/election) and $7,419 (287 partial QP elections x $25.85/election).
TABLE 24: Estimated Burden for Partial QP Election
Burden and Respondent Descriptions |
Burden Estimate |
# of respondents making Partial QP election (156 APM Entities, 131 eligible clinicians) (a) |
287 |
Total Hours Per Respondent to Elect to Participate as Partial QP (b) |
0.25 |
Total Annual Hours (c) = (a) [x] (b) |
72 |
Cost per Respondent at Labor rate for computer systems analyst @ $103.40/hr (d) = (b) [x] $103.40/hr |
$25.85 |
Total Annual Cost (e) = (a) [x] (d) |
$7,419 |
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 25, based on the actual number of requests received for in the 2021 QP performance period, we estimate that for the 2024 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. We estimate it would take 10 hours at $103.40/hr for a computer system analyst, resulting in a cost of $1,034 per submission. In aggregate, we estimate an annual burden of 150 hours (15 submissions x 10 hr/submission) and $15,510 (15 submissions x $1,034/submission) for the CY 2024 performance period/2026 MIPS payment year.
TABLE 25: 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) [x] (b) |
150 |
Ost per Respondent at Labor rate for computer systems analyst @ $103.40/hr (d) = (b) [x] $103.40/hr |
$1,034 |
Total Annual Cost (e) = (a) [x] (d) |
$15,510 |
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/.
As shown in Table 26, we estimate 15 other payer arrangements will be submitted by APM Entities and eligible Other Payer Advanced APM determinations in the CY 2024 performance period/2026 MIPS payment year. We estimate it would take 10 hours at $103.40/hr for a computer system analyst, resulting in a cost of $1,034 per submission. In aggregate, we estimate an annual burden of 150 hours (15 submissions x 10 hr/submission) at a cost of $15,510 (15 submissions x $1,034/submission) for the CY 2024 performance period/2026 MIPS payment year.
TABLE 26: 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) [x] (b) |
150 |
Ost per Respondent at Labor rate for computer systems analyst @ $103.40/hr (d) = (b) [x] $103.40/hr |
$1,034 |
Estimated Total Annual Cost (e) = (a) [x] (d) |
$15,510 |
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 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 shown in Table 27, 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 2024 performance period/2026 MIPS payment year. We estimate it will take the APM Entity representative, TIN representative, or eligible clinician 5 hours at $123.06/hr for a medical and health services manager to complete this submission, resulting in a cost of $615.30 per submission. In aggregate, we estimate an annual burden of 2,755 hours (551 submissions x 5 hr) at a cost of $339,030 (551 submissions x $615.30/submission).
TABLE 27: 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 clinicians submitting data for All-Payer QP Determinations (c) |
83 |
Total # of Respondents (d) = (a) + (b) + (c) |
551 |
Hours Per respondent QP Determinations (e) |
5 |
Total Hours (f) = (d) [x] (e) |
2,755 |
Cost per Respondent at Labor rate for a Medical and health services manager ($123.06/hr) (g) = (e) [x] $123.06/hr |
$615.30 |
Total Annual Cost (h) = (d) [x] (g) |
$339,030 |
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. 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 the CY 2019 performance period/2021 MIPS payment year will continue to do so in the CY 2024 performance period/2026 MIPS payment year.
For the CY 2024 performance period/2026 MIPS payment year, we estimate that 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 that will voluntarily opt-out of public reporting on Compare Tools.
As shown in Table 28, we estimate that it would take 0.25 hours at $103.40/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 $982 (38 requests x $25.85/request).
TABLE 28: Estimated Burden for Voluntary Participants to Elect Opt Out of Performance Data Display on Compare Tools
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) [x] (b) |
10 |
Cost per request at Labor rate for a computer systems analyst (d) = (b) [x] $103.40/hr |
$25.85 |
Total Annual Cost (e) = (a) [x] (d) |
$982 |
Table 29 below provide summaries of all burden estimates for each of the information collections included in this PRA for the CY 2024 performance period/2026 MIPS payment year. With respect to the PRA, the CY 2024 PFS final rule does not impose any non-labor costs.
TABLE 29: CY 2024 Performance Period/2026 MIPS Payment Year Burden Summary
Regulation Section(s) Under Title 42 of the CFR |
Table No. |
No. Respondents |
Total Responses |
Time per Response (hours) |
Total Time (hours) |
Labor Cost ($/hr) |
Total Cost ($) |
§414.1400 (Simplified Registry self- nomination) |
3 |
84 |
84 |
0.5 |
42 |
103.40 |
4,343 |
§414.1400 (Full Registry self- nomination) |
4 |
27 |
27 |
2 |
54 |
103.40 |
5,584 |
§414.1400 (Simplified QCDR self-nomination) |
5 |
44 |
44 |
9.5 |
418 |
103.40 |
43,221 |
§414.1400 (Full QCDR self-nomination) |
6 |
12 |
12 |
11.5 |
138 |
103.40 |
14,269 |
§414.1400 (Third Party Intermediary Plan Audits) |
8 |
126 |
126 |
Varies (see table 8) |
499 |
103.40 |
51,597 |
Open Authorization Credentialing and Token Request Process |
9 |
15 |
15 |
2 |
30 |
103.40 |
3,102 |
§414.1325 and 414.1335 (QPP Identity Management Application Process) |
10 |
6,500 |
6,500 |
1 |
6,500 |
103.40 |
672,100 |
§414.1325 and 414.1335 [(Quality Performance Category) Claims Collection Type] |
11 |
13,413 |
13,413 |
14.2 |
190,465 |
Varies (see table 11) |
21,303,868 |
§414.1325 and 414.1335 [(Quality Performance Category) QCDR/MIPS CQM Collection Type] |
12 |
16,632 |
16,632 |
9.083 |
151,068 |
Varies (see table 12) |
17,289,629 |
§414.1325 and 414.1335 [(Quality Performance Category) eCQM Collection Type] |
13 |
28,714 |
28,714 |
8.0 |
229,712 |
Varies (see table 13) |
26,633,958 |
§ 414.1365 MVP Registration |
14 |
9,585 |
9,585 |
0.25 |
2,396 |
103.40 |
247,772 |
§ 414.1365 Subgroup Registration |
15 |
20 |
20 |
0.5 |
10 |
103.40 |
1,034 |
§ 414.1365 MVP Quality Submission |
16 |
9,585 |
9,585 |
Varies |
61,662 |
Varies (see table 16) |
7,041,427 |
[(Quality Performance Category) Call for Quality Measures] |
17 |
31 |
31 |
5.5 |
171 |
Varies (see table 17) |
35,529 |
§414.1375 and 414.1380[(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories |
18 |
29,227 |
29,227 |
0.25 |
7,307 |
103.40 |
755,518 |
§414.1375 [(PI Performance Category) Data Submission] |
19 |
25,990 |
25,990 |
2.70 |
70,173 |
103.40 |
7,255,888 |
[(PI Performance Category) Call for Promoting Interoperability Measures] |
20 |
0 |
0 |
0.5 |
0 |
Varies (see table 20) |
0 |
§414.1360 [(Improvement Activities Performance Category) Data Submission] |
21 |
50,289 |
50,289 |
0.083 |
4,174 |
103.40 |
431,480 |
§414.1360 [(Improvement Activities Performance Category) Nomination of Improvement Activities] |
22 |
15 |
15 |
4.4 |
66 |
Varies (see table 22) |
11,755 |
Nomination of MVPs |
23 |
10 |
10 |
12 |
120 |
Varies (see table 23) |
22,033 |
§414.1430 [Partial Qualifying APM Participant (QP) Election] |
24 |
287 |
287 |
0.25 |
72 |
103.40 |
7,419 |
§414.1440 [Other Payer Advanced APM Identification: Payer Initiated Process] |
25 |
15 |
15 |
10 |
150 |
103.40 |
15,510 |
§414.1445 [Other Payer Advanced APM Identification: Clinician Initiated Process] |
26 |
15 |
15 |
10 |
150 |
103.40 |
15,510 |
§414.1440 [Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option] |
27 |
551 |
551 |
5 |
2,755 |
123.06 |
339,030 |
§414.1395 [(Physician Compare) Opt Out for Voluntary Participants] |
28 |
38 |
38 |
0.25 |
10 |
103.40 |
982 |
TOTAL |
n/a |
191,225 |
191,225 |
Varies |
728,142 |
Varies |
82,202,558 |
Information Collection Instruments/Instructions
We have included a list of the Appendices that we submitted in the CY 2024 final rule MIPS PRA package. We have revised Appendices, A1 through D1, and listed the relevant changes in the Appendices, A2 through D2. We also revised Appendices G1 through K1, and listed the relevant changes in Appendices G2 through K2. We note that we did not make any changes to the content in Appendices E, F, and L.
Appendix A1 (See Tables 3, 4, 5, 6, 7, and 8): 2024 MIPS QCDR and Registry Self-nomination User Guide (Revised)
Appendix A2 (See Tables 3, 4, 5, 6, 7, and 8): 2024 MIPS QCDR and Registry Self-nomination User Guide Crosswalk
Appendix B1 (See Table 25): 2024 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)
Appendix B2 (See Table 25): 2024 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
Appendix C1 (See Table 26): 2024 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) (Revised)
Appendix C2 (See Table 26): 2024 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) Crosswalk
Appendix D1 (See Table 27): 2024 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)
Appendix D2 (See Table 27): 2024 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option Crosswalk
Appendix E (See Table 17): Measures under Consideration 2023 Data Template for Candidate Measures
Appendix F (See Table 17): 2023 Peer Reviewed Journal Article Requirement Template
Appendix G1 (See Table 22): Improvement Activities Performance Category, 2024 Call for Activities Submission Form (Revised) (previously Appendix H)
Appendix G2 (See Table 22): Improvement Activities Performance Category, 2024 Call for Activities Submission Form Crosswalk
Appendix H1 (See Table 18): 2023 MIPS Promoting Interoperability Hardship Exception Application Guide (previously Appendix I) (Revised)
Appendix H2 (See Table 18): 2023 MIPS Promoting Interoperability Hardship Exception Application Guide Crosswalk
Appendix I1 (See Table 16): 2023 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (previously Appendix J) (Revised)
Appendix I2 (See Table 16): 2023 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide Crosswalk
Appendix J1 (See Table 23): 2024 MVP Candidates: Instructions and Template (previously Appendix K) (Revised)
Appendix J2 (See Table 23): 2024 MVP Candidates: Instructions and Template Crosswalk
Appendix K1 (See Table 24): 2023 Partial QP Election Form (for submission in CY 2024) (previously Appendix L) (Revised)
Appendix K2 (See Table 24): 2023 Partial QP Election Form (for submission in CY 2024) Crosswalk
Appendix L (See Tables 14 and 15): 2023 MVP Registration Form
This section is not applicable to the information collection discussed in this document.
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 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 $60.83/hr for a GS-13 Step 5 to nominate an improvement activity for a total cost of $182.49 (3 hrs x $60.83/hr) per activity.
The following changes are associated with our CY 2024 PFS final rule (CMS-1784-F; RIN 0938-AV07) which published in the Federal Register on November 16, 2023 (88 FR 78818).
In table 30 below, we illustrate the change in burden to our currently approved estimates. The estimated changes are due to new policy proposals set forth in the CY 2024 PFS final rule and adjustments to the currently approved burden as a result of updated data sources and assumptions.
TABLE 30: Change in Burden for CY 2024 Performance Period/2026 MIPS Payment Year
Burden Type |
Total Requested (A) |
Change Due to New Statute (B) |
Change Due to Program Discretion (C) |
Change Due to Program Adjustment (D) |
Total Currently Approved (E) |
Total Responses |
191,225 |
+1,365 |
0 |
+30,332 |
159,528 |
Total Time (hr) |
728,142 |
-4,147 |
0 |
+18,429 |
|
Total Cost ($) |
82,202,558 |
-477,101 |
0 |
+2,271,245 |
As shown above in table 30, the increase in 1,365 responses with a total decrease in burden of 4,147 hours and a decrease in cost of $477,101 due to new statutes (Column B) is due to the addition of 5 new MVPs to the existing MVP Inventory resulting in an increase in the number of respondents registering for MVP reporting (+1,365 responses and +341 hours) and an increase in the number of respondents submitting for the quality performance category of MVPs (+1,365 responses and +8,784 hours), and a decrease in the number of respondents submitting for the Medicare Part B Claims (-312 responses and -4,430 hours), MIPS CQM and QCDR (-386 responses and -3,506 hours), and eCQM (-667 responses and -5,336 hours) collection types. The remaining changes due to program adjustment (Column D) are entirely due to availability of updated data and assumptions. Table series 31 below provides additional detail as to the changes in burden for each information collection.
TABLE 31A: Burden Reconciliation for Simplified Qualified Registry Self-Nomination
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
Finalized (See Table 3) |
84 |
1 |
84 |
0.5 |
42 |
103.40 |
4,343 |
Adjustment |
+84 |
n/a |
+84 |
0.5 |
+42 |
n/a |
4,343 |
TABLE 31B: Burden Reconciliation for Full Qualified Registry Self-Nomination
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
132 |
1 |
132 |
2 |
264 |
103.40 |
27,298 |
Finalized (See Table 4) |
27 |
1 |
27 |
2 |
54 |
103.40 |
5,584 |
Adjustment |
-105 |
No change |
-105 |
No change |
-210 |
No change |
-21,714 |
Table 31C: Burden Reconciliation for Simplified QCDR
Self-Nomination and QCDR
Measure Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
Finalized (See Table 5) |
44 |
1 |
44 |
9.5 |
418 |
103.40 |
43,221 |
Adjustment |
+44 |
n/a |
+44 |
9.5 |
+418 |
n/a |
+43,221 |
TABLE 31D: Burden Reconciliation for Full QCDR Self-Nomination and
QCDR
Measure Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
63 |
1 |
63 |
10.1 |
636 |
103.40 |
65,793 |
Finalized (See Table 6) |
12 |
1 |
12 |
11.5 |
138 |
103.40 |
14,269 |
Adjustment |
-51 |
No change |
-51 |
+1.4 |
-498 |
No change |
-51,524 |
TABLE 31E: Burden Reconciliation for Third Party Intermediary Plan Audits
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
127 |
1 |
127 |
Varies |
585 |
103.40 |
60,489 |
Finalized (See Tables 7 and 8) |
126 |
1 |
126 |
Varies |
499 |
103.40 |
51,597 |
Adjustment |
-1 |
No change |
-1 |
Varies |
-86 |
No change |
-8,892 |
TABLE 31F: Burden Reconciliation for Open Authorization Credentialing and Token Request Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
15 |
1 |
15 |
2 |
30 |
103.40 |
3,102 |
Finalized (See Table 9) |
15 |
1 |
15 |
2 |
30 |
103.40 |
3,102 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31G: Burden Reconciliation for Quality Payment Program Identity Management Application Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost($/hr) |
Total Annual Cost ($) |
Currently Approved |
6,500 |
1 |
6,500 |
1 |
6,500 |
103.40 |
672,100 |
Finalized (See Table 10) |
6,500 |
1 |
6,500 |
1 |
6,500 |
103.40 |
672,100 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31H: Burden Reconciliation for Quality Performance Category
Claims
Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
14,736 |
1 |
14,736 |
14.2 |
209,251 |
Varies |
23,405,189 |
Finalized (See Table 11) |
13,413 |
1 |
13,413 |
14.2 |
190,465 |
Varies |
21,303,868 |
Adjustment |
-1,323 |
No change |
-1,323 |
No change |
-18,786 |
No change |
-2,101,321 |
TABLE 31I: Burden Reconciliation for Quality Performance Category QCDR/MIPS CQM Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
17,916 |
1 |
17,916 |
9.083 |
162,731 |
Varies |
18,624,399 |
Finalized |
16,632 |
1 |
16,632 |
9.083 |
151,068 |
Varies |
17,289,629 |
Adjustment |
-1,284 |
No change |
-1,284 |
No change |
-11,663 |
No change |
-1,334,770 |
TABLE 31J: Burden Reconciliation for Quality Performance Category
eCQM
Collection Type
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
23,889 |
1 |
23,889 |
8 |
191,112 |
Varies |
22,158,481
|
Finalized |
28,714 |
1 |
28,714 |
8 |
229,712 |
Varies |
26,633,958 |
Adjustment |
+4,825 |
No change |
+4,825 |
No change |
+38,600 |
No change |
+4,475,477 |
TABLE 31K: Burden Reconciliation for MVP Registration
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
7,731 |
1 |
7,731 |
0.25 |
1,933 |
103.40 |
199,846 |
Finalized |
9,585 |
1 |
9,585 |
0.25 |
2,396 |
103.40 |
247,772 |
Adjustment |
+1,854 |
No change |
+1,854 |
No change |
+463 |
103.40 |
+47,926 |
TABLE 31L: Burden Reconciliation for Subgroup Registration
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
20 |
1 |
20 |
0.5 |
10 |
103.40 |
1,034 |
Finalized |
20 |
1 |
20 |
0.5 |
10 |
103.40 |
1,034 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31M: Burden Reconciliation for MVP Quality Performance Category Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
7,731 |
1 |
7,731 |
Varies |
50,938 |
Varies |
5,807,193 |
Finalized (See Table 16) |
9,585 |
1 |
9,585 |
Varies |
61,662 |
Varies |
7,041,427 |
Adjustment |
+1,854 |
No change |
+1,854 |
No change |
+10,724 |
No change |
+1,234,234 |
TABLE 31N: Burden Reconciliation for Call for Quality Measures
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
29 |
1 |
29 |
5.5 |
160 |
Varies |
33,237 |
Finalized (See Table 17) |
31 |
1 |
31 |
5.5 |
171 |
Varies |
35,529 |
Adjustment |
+2 |
No change |
+2 |
No change |
+11 |
No change |
+2,292 |
TABLE 31O: Burden Reconciliation for Reweighting Applications for Promoting Interoperability and Other Performance Categories
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
5,439 |
1 |
5,439 |
0.25 |
1,360 |
103.40 |
140,598 |
Finalized (See Table 18) |
29,227 |
1 |
29,227 |
0.25 |
7,307 |
103.40 |
755,518 |
Adjustment |
+23,788 |
No change |
+23,788 |
No change |
+5,947 |
No change |
+614,920 |
TABLE 31P: Burden Reconciliation for Promoting Interoperability Performance Category Data Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
30,107 |
1 |
30,107 |
2.70 |
81,289 |
103.40 |
8,405,272 |
Finalized (See Table 19) |
25,990 |
1 |
25,990 |
2.70 |
70,173 |
103.40 |
7,255,888 |
Adjustment |
-4,117 |
No change |
-4,117 |
No change |
-11,116 |
No change |
-1,149,384 |
TABLE 31Q: Burden Reconciliation for Call for Promoting Interoperability Measures
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
10 |
1 |
10 |
0.5 |
5 |
Varies |
918 |
Finalized (See Table 20) |
0 |
n/a |
10 |
n/a |
0 |
n/a |
0 |
Adjustment |
-10 |
n/a |
-10 |
n/a |
-5 |
n/a |
-918 |
TABLE 31R: Burden Reconciliation for Improvement Activities Submission
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
44,136 |
1 |
44,136 |
0.083 |
3,663 |
103.40 |
378,687 |
Finalized (See Table 21) |
50,289 |
1 |
50,289 |
0.083 |
4,174 |
103.40 |
431,480 |
Adjustment |
+6,153 |
No change |
+6,153 |
No change |
+511 |
No change |
+52,793 |
TABLE 31S: Burden Reconciliation for Nomination of Improvement Activities
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
31 |
1 |
31 |
4.4 |
136 |
Varies |
24,294 |
Finalized (See Table 22) |
15 |
1 |
15 |
4.4 |
66 |
Varies |
11,755 |
Adjustment |
-16 |
No Change |
-16 |
No change |
- 70 |
Varies |
-12,539 |
TABLE 31T: Burden Reconciliation for Nomination of MVPs
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
10 |
1 |
10 |
12 |
120 |
Varies |
22,033 |
Finalized (See Table 23) |
10 |
1 |
10 |
12 |
120 |
Varies |
22,033 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31U: Burden Reconciliation for Partial QP Election
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
287 |
1 |
287 |
0.25 |
72 |
103.40 |
7,419 |
Finalized (See Table 24) |
287 |
1 |
287 |
0.25 |
72 |
103.40 |
7,419 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31V: Burden Reconciliation for Other Payer Advanced APM Identification: Other Payer Initiated Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
15 |
1 |
15 |
10 |
150 |
103.40 |
15,510 |
Finalized (See Table 25) |
15 |
1 |
15 |
10 |
150 |
103.40 |
15,510 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31W: Burden Reconciliation for Other Payer Advanced APM Identification: Eligible Clinician Initiated Process
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
15 |
1 |
15 |
10 |
150 |
103.40 |
15,510 |
Finalized (See Table 26) |
15 |
1 |
15 |
10 |
150 |
103.40 |
15,510 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31X: Burden Reconciliation for Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
551 |
1 |
551 |
5 |
2,755 |
123.06 |
339,030 |
Finalized (See Table 27) |
551 |
1 |
551 |
5 |
2,755 |
123.06 |
339,030 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
TABLE 31Y: Burden Reconciliation for Voluntary Participants to Elect to Opt Out of Performance Data Display on Physician Compare
Burden Category |
Total Annual Respondents |
Response Frequency (per year) |
Total Annual Responses |
Time Per Response (hr) |
Total Annual Time (hr) |
Labor Cost ($/hr) |
Total Annual Cost ($) |
Currently Approved |
38 |
1 |
38 |
0.25 |
10 |
103.40 |
982 |
Finalized (See Table 28) |
38 |
1 |
38 |
0.25 |
10 |
103.40 |
982 |
Adjustment |
No change |
No change |
No change |
No change |
No change |
No change |
No change |
Table 32 provides the reasons for changes in the estimated burden for finalized policies and information collections for the CY 2024 performance period/2026 MIPS payment year set forth in the CY 2024 PFS final rule. We have divided the reasons for our change in burden into those related to newly finalized policies and those related to updated data and methods for the CY 2024 performance period/2026 MIPS payment year burden set forth in the CY 2023 PFS final rule.
TABLE 32: Reasons for Change in Burden Compared to the Currently
Approved
CY 2023 Information Collection Burdens
Table in Collection of Information |
Changes in burden due to finalized CY 2024 policies |
Adjustments in burden continued from CY 2023 PFS final rule policies due to revised methods or updated data |
Table 31A: Simplified Qualified Registry Self-Nomination and Other Requirements |
None |
Increase of 84 respondents and 42 hours due to the addition of a new ICR. |
Table 31B: Full Qualified Registry Self-Nomination and Other Requirements |
None |
Decrease of 105 respondents and 210 hours due to updated data assumptions. |
Table 31C: Simplified QCDR Self-Nomination and Other Requirements |
None |
Increase of 44 respondents and 418 hours due to the addition of a new ICR. |
Table 31D: Full QCDR Self-Nomination and Other Requirements |
None |
Decrease of 51 respondents and 498 hours due to updated data assumptions. |
Table 31E Third Party Intermediary Plan Audits |
None |
Decrease of 1 respondent and 86 hours due to updated data assumptions. |
Table 31F: Open Authorization Credentialing and Token Request Process |
None |
None |
Table 31G: Quality Payment Program Identity Management Application Process |
None |
None |
Table 31H: Quality Performance Category Claims Collection Type |
Decrease of 312 respondents and 4,430 hours due to the estimated increase in the number of respondents submitting for the MVP quality performance category via the claims collection type. |
Decrease of 1,011 respondents and 14,356 hours due to updated data assumptions. |
Table 31I: Quality Performance Category QCDR/MIPS CQM Collection Type |
Decrease of 386 respondents and 3,506 hours due to the estimated increase in the number of respondents submitting for the MVP quality performance category via the QCDR and MIPS CQM collection type. |
Decrease of 898 respondents and 8,157 hours due to updated data assumptions. |
Table 31J: Quality Performance Category eCQM Collection Type |
Decrease of 667 respondents and 5,336 hours due to the estimated increase in the number of respondents submitting for the MVP quality performance category via the eCQM collection type. |
Increase of 5,492 respondents and 43,936 hours due to updated data assumptions. |
Table 31K MVP Registration |
Increase of 1,365 respondents and 341 hours due to the addition of 5 new MVPs. |
Increase of 489 respondents and 122 hours due to updated data assumptions. |
Table 31L: Subgroup Registration |
None |
None |
Table 31M: MVP Quality Performance Category Submission |
Increase of 1,365 respondents and 8,784 hours due to the addition of 5 new MVPs. |
Increase of 489 respondents and 1,940 hours due to updated data assumptions. |
Table 31N: Call for Quality Measures |
None |
Increase of 2 respondents and 11 hours due to updated data assumptions. |
Table 31O: Reweighting Applications for Promoting Interoperability and Other Performance Categories |
None |
Increase of 23,788 respondents and 5,947 hours due to updated data assumptions. |
Tables 31P: Promoting Interoperability Performance Category Data Submission |
None |
None |
Table 31Q: Call for Promoting Interoperability Measures |
None |
Decrease of 10 respondents and 5 hours due to the removal of ICR. |
Table 31R: Improvement Activities Submission |
None |
None |
Table 31S: Nomination of Improvement Activities |
None |
Decrease of 16 respondents and 70 hours due to updated data assumptions. |
Table 31T: Nomination of MVPs |
None |
None |
Table 31U: Partial QP Election |
None |
None |
Table 31V: Other Payer Advanced APM Identification: Other Payer Initiated Process |
None |
None |
Table 31W: Other Payer Advanced APM Identification: Eligible Clinician Initiated Process |
None |
None |
Table 31X: Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option |
None |
None |
Table 31Y: Voluntary Participants to Elect to Opt Out of Performance Data Display on Physician Compare |
None |
None |
Table 33 below provides a snapshot of the estimated burden described above in Table 29. Additionally, we have included the estimated total number of unique respondents that will submit data for the quality, Promoting Interoperability, and improvement activity performance categories in the CY 2024 performance period/2026 MIPS payment year. With the exception of extreme and uncontrollable circumstances 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. With respect to the PRA, the estimated burden in the CY 2024 PFS final rule does not impose any non-labor costs.
Table 33: Quality Payment Program Annual Requirements and Burden Regulation Section(s) Under Title 42 of the CFR
Burden Category |
Burden Estimate |
No. of Unique Respondents |
92,604 |
Total # of Responses |
191,225 |
Time per Response (Hours) |
Varies |
Total Annual Time (Hours) |
728,142 |
Labor Cost ($/hr) |
Varies |
Total Cost ($) |
82,202,558 |
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 Compare Tools 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, 2019, 2020 and 2021 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 claims.
2 The use of CMS-approved survey vendors is not included in this PRA package. CMS will request 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 2024 PFS final 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.
| 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 | 2023-11-20 |