The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, overseen by the CAHPS Consortium, are used by CMS to evaluate patient experiences. These standardized surveys are crucial for the Value-Based Purchasing initiatives, where CMS rewards high-quality services based on clinical, administrative, and patient care evaluations.
The CAHPS for MIPS Survey is an optional quality measure that MIPS eligible clinicians participating in a group, subgroup, virtual group, or Alternative Payment Model (APM) Entity, including Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs), can elect to administer. Only these groups can opt to use the CAHPS for MIPS Survey, reported by CMS-approved vendors, to enhance their quality reporting. This survey is not available for individual clinicians.
Advance registration is required for any group, virtual group, subgroup, and APM Entity (except Shared Savings Program ACOs) that intends to administer the CAHPS for MIPS survey. Registration closes at 8 p.m. ET on June 30, 2023. If a group opts for the CAHPS survey, they must:
- Hire a CMS-approved vendor to collect and submit data.
- Bear the vendor’s costs.
- Monitor the vendor’s performance.
- Receive their survey scores from CMS.
The survey scores may be publicly reported on the Medicare.gov website. Groups not providing primary care (e.g. surgeons) may find this survey unsuitable.
What is the CAHPS for MIPS Survey?
The CAHPS for MIPS Survey evaluates patients’ experience of care within a group, subgroup, virtual group, or APM Entity. The 2023 survey contains 10 summary survey measures to assess the following:
- Getting Timely Care, Appointments, and Information
- How Well Providers Communicate
- Patient’s Rating of Provider
- Access to Specialists
- Health Promotion and Education
- Shared Decision Making
- Courteous and Helpful Office Staff
- Care Coordination
- Stewardship of Patient Resources
- Health Status and Functional Status
Reporting Criteria for 2023
For clinicians reporting Traditional MIPS, the CAHPS for MIPS Survey is an optional measure for groups, virtual groups, and APM Entities with 2+ eligible clinicians. It counts as one measure toward MIPS quality performance and satisfies the need for a high-priority measure.
For clinicians reporting MIPS Value Pathways (MVPs), the CAHPS for MIPS Survey is an optional measure for groups, subgroups, and APM Entities with 2+ eligible clinicians that are registered to report certain MVPs. If the CAHPS for MIPS Survey is available within the selected MVP, it can be reported as 1 of the 4 required quality measures.
Groups using the APP must use this survey, while Shared Savings Program ACOs are automatically registered. MVP subgroups face the same requirements as other groups.
CAHPS for MIPS Survey Registration
Participation in the survey requires registration online between April 3 – June 30, 2023. You’ll be informed by Fall 2023 if you’re eligible, based on sample size. If your sample size is insufficient, you can’t administer the survey.
To register for the CAHPS for MIPS Survey:
- Sign in to QPP.
- Go to the Registration page.
- Click “Start Registration.”
- Click “Register and Edit CAHPS Registration.”
- If you have multiple organizations on your account, select the organization you wish to register and click “Register Group for CAHPS.”
To register, you’ll need to have the Security Official role for your organization. Please refer to the QPP Access User Guide for more information.
Vendor Selection and Survey Administration
What is a CMS Approved Survey Vendor?
The CAHPS for MIPS Survey may only be administered by CMS-approved vendors. CMS approves vendors to conduct the CAHPS for MIPS Survey after they complete training and submit a quality plan. Groups and APM Entities, including Shared Savings Program ACOs, will work with these approved vendors. The survey, conducted from October 2023 to January 2024, measures patients’ experiences with their healthcare providers. The approved vendors will collect and submit this data for the entities. CMS will certify vendors who are equipped and experienced to conduct the CAHPS for MIPS Survey. Groups and APM Entities, including Shared Savings Program ACOs, must hire a CMS-approved vendor for survey administration and bear its costs. You can find a public list of approved vendors here.
Administering the CAHPS for MIPS Survey
The survey will be administered through a mixed-mode data collection protocol that includes:
- CMS prenotification letter
- Up to 2 survey mailings
- Up to 6 follow-up attempts to complete the survey by phone with patients who don’t return a survey by mail.
Frequently Asked Questions
Q: When will the CAHPS for MIPS Survey be conducted?
A: The survey is conducted on an annual basis. The 2023 survey will be conducted from October 2023 through January 2024.
Q: Who pays to administer the CAHPS for MIPS Survey?
A: Groups, subgroups, virtual groups, and APM Entities, including Shared Savings Program ACOs, are responsible for the costs associated with the survey administration and must contract with a CMS approved survey vendor to conduct the survey. A list of approved vendors will be posted on the Quality Payment Program Resource Library.
Q: Who identifies which patients are eligible to participate in the survey?
A: CMS will identify patients eligible for the survey from the pool of
Medicare fee-for-service (FFS) patients assigned to the groups, subgroups, virtual groups, Shared Savings Program ACOs, and other APM Entities.
For more information on CAHPS for MIPS, you can view the Center for Medicare and Medicaid Services website.