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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 CAHPS for MIPS survey is an optional quality measure that groups participating in MIPS can elect to administer.  The CAHPS for MIPS survey is also an optional improvement activity that groups can attest to administering. 

About the Survey: The 2018 Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey measures ten key domains of beneficiaries’ experiences of care that we refer to as summary survey measures (SSMs). An 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 CMS information needs. The survey will be administered through a Mixed-Mode data collection protocol, including: CMS pre-notification letter, two survey mailings, and up to six follow-up phone calls to beneficiaries who do not return a survey by mail. All final CAHPS for MIPS survey documents can be found on the Quality Payment Program 2018 resource library.

Information for Survey Vendors: The Centers for Medicare & Medicaid Services (CMS) is accepting vendor applications through March 20, 2018. The CAHPS for MIPS survey may only be administered by CMS-approved vendors. If you are interested in becoming a CMS-approved CAHPS for MIPS 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 application 

  • Complete and submit the vendor participation application by March 20, 2018. 
  • All vendors with approved participation applications will be placed on a list of conditionally approved CAHPS for MIPS 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 beneficiary selection. Organizations must also submit a Quality Assurance Plan. 

Approved vendors must follow the procedures and specifications provided by CMS to assure their client’s data will be accepted and to maintain their CAHPS for MIPS 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 mipscahps@hcqis.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: 04/30/2020). 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 2018 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 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). 

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