Form CMS-10898 Non-participating Small and Solo Practices Survey

Survey Guide

Demographics
Q1. Size [select one]	Approximately how many clinicians/providers total are annually eligible for the Merit-Based Incentive Payment System (MIPS) through your organization? 1 2-5 6-15 More than 15 [skip to end]
Q2. Type [Select one]	Which best describes the type of care provided by your practice? Primary Care Specialty Multi-specialty
Q3. Location	Is your practice rural and/or located in a Health Professional Shortage Area (HPSA)? Yes No Not sure
Q4. Experience [Select one]	How long have you worked for your current practice? Less than a year 1-3 years 3-6 years 7 years or more
Q5. Role [Select one]	Which best describes your role within the practice? Clinician Office Manager Billing Specialist Other [specify]
Q6. QPP Experience [Yes/No]	Have you ever been personally involved in data collection and submission for MIPS? Yes No
Q7. SURS	Did your practice previously receive free technical assistance from a CMS-sponsored program called the Small, Underserved, and Rural? Yes No Not sure
MIPS Participation
Q8. Decision [Select All that Apply]	Which of the following options describe why your practice did not submit data for the 2022 Performance Year? Select all that apply Unaware of clinician eligibility Unclear requirements Data collection and submission too burdensome Technological limitations Lack of applicable Quality measures Costs of reporting were too high Lack of administrative support to manage process Other [specify]
Q9. Penalty [Yes/No]	Were you aware that a MIPS Eligible Clinician may receive a negative 9% payment adjustment as a penalty for non-participation? Yes No
Q8. EHR [Yes/No]	Does your practice use an Electronic Medical Records (EMR) or Electronic Health Records (EHR) system? Yes No (if yes) Does your EMR/EHR support data collection for measures that meet MIPS requirements? Yes No (if no) Are you familiar with the process that allows practices to report Quality measures for MIPS as part of regular Medicare Claims processing? Yes No
Q9. Future Participation [Select one]	Are you planning to submit data for MIPS in the future? Yes, definitely Undecided No (If yes) What has changed that will lead you to reporting in the future? [Open text field] (if undecided) What do you still need to consider before you make a decision about future reporting? [Open text field] (if no) Why have you decided not to report data in the future?
Q10. Changes [Select all that apply]	What changes could CMS make that would improve the chances your practice would report data to MIPS? Change reporting requirements New Quality measures Better informational resources (user guides, etc.) Return of free technical assistance Other (specify) None of the above
Q11. Newsletter [Yes/No]	Are you aware of the monthly QPP Small Practice Newsletter that includes information specific to small practices about participation including help resources and key deadlines? Yes No
Q12. Open Response [Text Field]	Please use the space below to provide any additional feedback you would like to share with CMS and QPP regarding your experience with MIPS.
Q13. Interview	Would you be willing to participate in an interview with a member of the QPP User Research team to share more information about your experience with MIPS reporting? Yes No (if yes) Please provide your information below and a member of our team will be in touch Name Email address

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1399 (Expiration date: 08/31/2024). The time required to complete this information collection is estimated to average 0.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact QPP at [email protected] 

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