CAHPS for MIPS Survey
Overview: The Merit-based Incentive Payment System (MIPS) is one track of the Quality Payment Program, where clinicians earn a performance-based payment adjustment to their Medicare payment. Clinicians participating in MIPS have the flexibility to choose the measures and activities that are most meaningful to their practice to demonstrate performance. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an optional quality measure that groups and virtual groups participating in MIPS can elect to administer. The CAHPS for MIPS Survey is also an optional improvement activity that groups and virtual groups can attest to administering.
About the Survey: The CAHPS for MIPS Survey measures 10 key domains of patients’ experiences of care that we refer to as summary survey measures (SSMs). A SSM is a collection of survey items that assess the same patient experience domain of care. The survey contains the core CAHPS Clinician & Group Survey (CG-CAHPS), plus additional items to meet the Centers for Medicare & Medicaid Services’s (CMS) information needs. The survey will be administered through a Mixed-Mode data collection protocol, including: CMS pre-notification letter, 2 survey mailings, and up to 6 follow-up phone calls to patients who do not return a survey by mail. All final CAHPS for MIPS Survey documents and informational materials can be found on the Quality Payment Program resource library.
Information for Survey Vendors: CMS is accepting vendor applications until 5:00 p.m. Eastern Daylight Time (EDT) on Wednesday, March 18, 2020. The CAHPS for MIPS Survey may only be administered by CMS-approved vendors. If you are interested in becoming a 2020 CMS-approved CAHPS for MIPS Survey vendor, review the minimum business requirements for survey vendors and confirm your organization meets these requirements. There is a two-step vendor approval process:
Step 1 – Vendor participation form application
- Complete and submit the vendor participation form application by 5:00 p.m. EDT on Wednesday, March 18, 2020.
- All vendors with approved participation form applications will be placed on a list of conditionally approved CAHPS for MIPS Survey vendors. Vendors must complete Step 2 to obtain final approval from CMS.
Step 2 – Successful completion of vendor training and submission of a Quality Assurance Plan
- Conditionally approved vendors (vendors’ and subcontractors’ key staff) must participate in training and pass an assessment at the end of the training session. The training covers an overview and background of MIPS, scoring and reporting of the CAHPS for MIPS Survey, and survey sample design and patient selection. Organizations must also submit a Quality Assurance Plan.
Approved vendors must follow the procedures and specifications provided by CMS to assure their clients’ data will be accepted and to maintain their CAHPS for MIPS Survey approval status. Approved vendors will participate in additional self and webinar trainings. If you need help completing the application, please contact the CAHPS for MIPS Survey Project Team by email at firstname.lastname@example.org. For more information on the Quality Payment Program go to https://qpp.cms.gov/.
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 0938-1222 (Expiration date: 01/31/2022). The time required to complete this information collection is estimated to average 10 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@cms.hhs.gov. All final CAHPS for MIPS Survey vendor documents can be found on the Quality Payment Program resource library.
Public reporting and policy relevance: The CAHPS for MIPS Survey scores are available for public reporting on the Physician Compare website annually. Public reporting of the CAHPS for MIPS Survey scores helps people with Medicare make objective and meaningful health care decisions. For more information on public reporting and Physician Compare contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222).