CAHPS for MIPS Survey: 6 Things You Need to Know

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey is an optional exercise that Groups of 2 or more providers can elect to complete to substitute for one of the 6 required measures in the Quality Category. The CAHPS for MIPS survey measures patient experience and care within a group. Are you planning to submit CAHPS for MIPS survey as a Quality measure for MIPS 2019? Here are 6 things you need to know about what constitutes this measure, and how is it scored.

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1.Components of CAHPS for MIPS Survey

CAHPS for MIPS survey counts as one Quality measure, but being a patient experience measure, it is eligible for 2 bonus points. The 2019 survey contains 10 summary survey measures to assess the following:

  1. Getting Timely Care, Appointments, and Information

  2. How Well Providers Communicate

  3. Patient’s Rating of Provider

  4. Access to Specialists

  5. Health Promotion and Education

  6. Shared Decision Making

  7. Health Status and Functional Status

  8. Courteous and Helpful Office Staff

  9. Care Coordination

  10. Stewardship of Patient Resources

 

2.CAHPS for MIPS Survey Measure Requirements

  • The survey is geared towards primary care.

  • It is only available to groups of 2 or more providers (not for providers submitting as individuals).

  • A CMS approved survey vendor must be used to submit this survey.

  • The practice is responsible for paying the vendor.

  • The survey vendors will send the survey results directly to the practice and CMS. These results will be reported on Physician Compare website and providers WILL NOT be able to delete the results.

  • Providers must register and declare that they will be contracting a vendor to do the CAHPS Survey by July 1, 2019. If they miss the deadline, they cannot do the survey for 2019.

 

3.Minimum Number of Patients Required

  • For large groups or virtual groups of 100 or more eligible clinicians: If there are fewer than 416 beneficiaries, the survey cannot be conducted

  • For groups or virtual groups of 25 to 99 eligible clinicians: If the group has fewer than 255 beneficiaries, the survey cannot be conducted

  • For groups or virtual groups of 2 to 24 eligible clinicians: If the group has fewer than 125 beneficiaries, the survey cannot be conducted

 

4. Scoring the CAHPS for MIPS Survey Measure

The CAHPS for MIPS Measure is considered as a “Yes” for the submission as opposed to requiring a numerator and denominator.

Patient Experience Measures and Outcome measures are special types of High Priority measures that earn 2 bonus points instead of just 1 bonus point for other High Priority measures.

Patient Experience Measures and Outcome measures are special types of High Priority measures that earn 2 bonus points instead of just 1 bonus point for other High Priority measures.

  • If the patient minimums are met, providers will receive 10 points for this measure IF they also submit the remaining 5 measures.

  • It can count as a High Priority measure IF an Outcome measure is not available.

  • It will earn 2 bonus points IF another Outcome measure is also being reported.

  • If patient minimum is not met, the measure will not be scored for the group and the Quality category maximum points would be reduced by 10. For a group not required to submit All-Cause Hospital Readmission Measure, the Quality score will then be calculated out of 50 points instead of 60 points.

5.CAHPS for MIPS Survey Results Reconciliation by CMS

CMS will reconcile the CAHPS for MIPS submission by matching the practice registration (done by July 1st 2019), the completed survey (done between Oct 1st and January 31st ,2020) and the MIPS submission (completed by March 31st 2020).

 

6.Additional Benefit for Improvement Activities Category

The practice will also be able to select the CAHPS for MIPS survey as one of the Improvement Activities (it is a High weight measure – 20 points). A small practice would earn 40 points owing to the flexibility of earning twice the points applicable.

 

How Can MyMipsScore™ Help?

MyMipsScore™ allows the practice submitting as a Group, to select the CAHPS for MIPS Measure the same way that they select the other measures. The CAHPS for MIPS Measure will be calculated and submitted along with the other measures.

If you are planning to utilize CAHPS for MIPS survey for 2019 performance year, ensure that you register by the July, 1, 2019 deadline. Do keep in mind that the other Quality measures will account for approximately 5/6th of your Quality score. For 2019, you can mix and match Quality measures from multiple collection types. Picking the measures that are best suited for your practice is essential for maximizing the effectiveness of your efforts and the payment adjustment.

MyMipsScore provides you with the ability to do a full analysis of every aspect for your specific MIPS possibilities. You can determine the best Clinical Quality Measures and track the progress throughout the year. Additionally, you will be able to document the PI and IA categories. MyMipsScore will dynamically produce your MIPS Composite Score (CPS) and calculate the potential incentive dollars based on the MIPS score.


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