CAHPS for MIPS Survey

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. Additional information can be found in the 2024 CAHPS for MIPS Survey Overview Fact Sheet (PDF, 631KB). 

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 2024 Physician Fee Schedule Final Rule (PDF, 213MB) and in the 2024 Quality Payment Program Final Rule Resources (ZIP, 1MB). 

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 is administered in English and Spanish, with optional translations available (Cantonese, Korean, Mandarin, Portuguese, Russian, and Vietnamese). 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.
• Up to 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 posted to the QPP Resource Library.

Information for Groups, Subgroups, Virtual Groups, and APM Entities (including Shared Savings Program ACOs): Each performance period, organizations reporting the CAHPS for MIPS Survey must:

• Contract with a CMS-approved survey vendor to administer the survey on their behalf. The list of CMS-approved survey vendors for the 2024 performance period will be posted to the QPP Resource Library later this year. 
• Authorize a CMS-approved survey vendor to collect and report their CAHPS for MIPS Survey data to CMS. All organizations will receive email instructions for completing survey vendor authorization in the summer. For Shared Savings Program ACOs, the instructions are emailed to the Authorized to Sign-Primary contact listed in ACO-MS. For all other organizations, the instructions are emailed to the contact entered into the CAHPS for MIPS Survey Registration System.

Each performance period, CMS posts updated information and resources for the CAHPS for MIPS Survey to the QPP Resource Library.

Information for Survey Vendors: The CAHPS for MIPS Survey may only be administered by CMS-approved vendors. CMS approves vendors on an annual basis. Information on the requirements and the process for approval can be found in the 2024 CAHPS for MIPS Minimum Business Requirements (PDF, 277KB) and the 2024 CAHPS for MIPS Vendor Participation Form (PDF, 967KB). For the 2024 performance period survey administration, CMS accepted vendor applications from Monday, April 1, 2024 until Monday, April 22, 2024. CMS will provide the application dates for the 2025 performance period in the future. 

Public reporting and policy relevance: A subset of the CAHPS for MIPS Survey annual scores are publicly reported for MIPS eligible clinicians on clinician and group profile pages under the Doctors and Clinicians section on the compare tool of the Medicare.gov website and in the Provider Data Catalog. 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.