Overview: The Merit-based Incentive Payment System (MIPS) is one track of the Quality Payment Program (QPP), where clinicians may earn a performance-based payment adjustment to their Medicare payment. Clinicians participating in MIPS have the flexibility to choose the measures from 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. For additional information, please visit the QPP website.
Since the 2021 performance period, Medicare Shared Savings Program Accountable Care Organizations (ACOs) have been required to report via the Alternative Payment Model (APM) Performance Pathway (APP) and report the CAHPS for MIPS Survey. The final policies can be found in the CY 2022 Physician Fee Schedule Final Rule (PDF) and in the 2022 Quality Payment Program Final Rule Resources (ZIP).
About the Survey: The CAHPS for MIPS Survey measures 10 key domains of patients’ experience of care that we refer to as summary survey measures (SSMs). A SSM is a collection of survey items that assess the same patients’ experience domain of care. The survey contains the core CAHPS Clinician & Group Survey (CG-CAHPS), plus additional items to measure patients’ experience of care. The survey will be administered through a Mixed-Mode (mail survey administration followed by Computer-Assisted Telephone Interview [CATI] administration with non-respondents) data collection protocol, including:
- CMS pre-notification letter.
- 2 survey mailings.
- Up to 6 follow-up phone calls to patients who don’t return a survey by mail.
All final CAHPS for MIPS Survey documents and informational materials are on the QPP Resource Library.
Information for Survey Vendors: The CAHPS for MIPS Survey may only be administered by CMS-approved vendors. For the 2022 performance period survey administration, CMS accepted vendor applications from Monday, April 4, 2022, until Monday, April 25, 2022. CMS anticipates a similar timeline for the 2023 performance period survey administration vendor applications. The 2022 CAHPS for MIPS Minimum Business Requirements (PDF) for survey vendors can be referenced on the QPP Resource Library. The 2023 CAHPS for MIPS Minimum Business Requirements will be posted in advance of the 2023 vendor application period. There’s a two-step vendor approval process:
Step 1 – Vendor participation form application
- Complete and submit the vendor participation form application.
- 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 (QAP)
- Conditionally approved vendors (vendors’ and subcontractors’ key staff) must participate in training and pass an assessment at the end of the training session. This self-guided computer-based training will cover content related to:
- Overview and background.
- Sample design and patient selection.
- Data analysis and public reporting.
- Program requirements.
- CMS data use agreement (DUA) and data safeguarding.
- Data collection protocol.
- Vendor oversight.
- Organizations must also submit a QAP that conforms to the model QAP provided by CMS.
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 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 additional information, please visit the QPP website.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1222 (Expiration date: 03/31/2024). 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 QPP Resource Library.
Public reporting and policy relevance: The CAHPS for MIPS Survey scores are available for public reporting on the Care 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 Care Compare, contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222), Monday through Friday from 8 a.m. to 8 p.m. ET. To receive assistance more quickly, please consider calling during non-peak hours—before 10 a.m. and after 2 p.m. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.