Response to Public Comments

CMS Response to Public Comments Received for CMS-10621

The Centers for Medicare and Medicaid Services (CMS) received two comments from a specialty society related to our burden estimates for two information collections in the CY 2022 PFS proposed rule. Specifically, the commenter did not agree with our estimates of the time required for QCDRs and qualified registries to submit data audits. The commenter also shared their belief that our estimate the clinicians that would participate in MVP reporting for CY 2023 performance period/2025 MIPS payment year is low. We have provided a summary of the comments and responses below.

Comment:

One commenter did not agree with CMS burden estimates for audits conducted by QCDRs and qualified registries and shared their belief that the time required for a QCDR was two to three-fold more than CMS estimates.

Response:

We thank the commenter for their feedback. The commenter shared their concern that our estimate does not accurately represent the total amount of time it takes for a QCDR or qualified registry to conduct data audits. We would like to clarify that our burden estimates provided for the QCDR, and qualified registry self-nomination process do not include the estimated time required for a QCDR, and a qualified registry to conduct data validation audits. The requirement for QCDRs and qualified registries to perform data validation is outside of the self-nomination process and we are unable to provide an estimate as the time may vary based on the number of clinicians, groups, and virtual groups supported by the QCDR or qualified registry and the number of applicable measures. Our burden estimate of 9.5 hours to 11.5 hours for the QCDR, and 0.5 hours to 2 hours for the qualified registry self-nomination process specifically includes the estimated time it takes for a QCDR or qualified registry to populate and submit a self-nomination form and QCDR measures, if applicable. These burden estimates do not include the time needed for QCDRs, and qualified registries to comply with the requirements outside of the self-nomination process. Additionally, our estimates are not intended to capture the holistic total annual time for a QCDR or a qualified registry to participate in MIPS. We believe our burden estimate is a reasonable average across all respondents based on our review of the nomination process, the information required to complete the nomination form, and the criteria required to self-nominate as a QCDR or registry.

Action Taken:

Due to the reasons detailed above in our response, we are not making any changes to our estimates of the time required for the QCDR and qualified registry self-nomination process.

Comment:

One commenter stated that our estimate that 10% of eligible clinicians would report as MVP participants in the first year of implementation is low. The commenter shared their belief that the number of MVP participants would be higher because of the reduced reporting burden associated with MVP reporting. 

Response:

We thank the commenter for their feedback. We acknowledge the commenter’s concern that our assumptions for MVP reporting are low. We agree with the commenter that MVP reporting is associated with a reduction in reporting burden. However, we believe that our estimates are appropriate because there would be a limited number of MVPs available for all clinicians during the CY 2023 performance period/2025 MIPS payment year. We expect that there would be increased participation in MVP reporting as more MVPs become available for clinicians in future years. We plan to revise our estimates for future years as more data becomes available. 

Action Taken:

Due to the reasons detailed above in our response, we are not making any changes our proposed estimate for the number of MIPS eligible clinicians that would participate in MVP reporting during the CY 2023 performance period/2025 MIPS payment year.