Unlike MIPS PY 2022, QPP has provided only 5 collection types for measures reporting in MIPS 2023. One of them is CAHPS for MIPS Survey. Here acronym CAHPS stands for ‘The Consumer Assessment of Healthcare Providers and Systems’. It is a certified trademark of the Agency for Healthcare Research and Quality (AHRQ). Mainly, this program performs various surveys and rates patient experiences. For this purpose, AHRQ collaborates with a consortium of research organizations. Therefore, the survey designed under CAHPS accosted patients and consumers directly. By evaluating the survey data, AHRQ can rate the patients’ experiences with health plans, providers, and healthcare facilities.
Above, we have provided a short introduction to CAHPS for you. Actually, CAHPS reports its research and findings to concerned agencies. Thereby, the same it does in MIPS reporting. As mentioned above, CAHPS in MIPS Survey acts as a collection type. The Consumer Assessment of Healthcare Providers and Systems does this job for those who register for this job. Like all other collection types, there is a procedure for its registration.
Here, we will see who and how QPP MIPS participants can appear in MIPS 2023 using CAHPS for MIPS Reporting.
CAHPS for MIPS Survey; Optional or Required?
As we have different participation types that choose different reporting pathways for MIPS reporting. Among these participation types are the following given below:
- Group;
- Subgroup;
- Virtual group;
- Alternative Payment Model (APM) Entity;
- Including Shared Savings Program Accountable Care Organizations (ACOs).
Likewise, QPP MIPS has three pathways for participants; Traditional MIPS, MVPs, and APPs. Therefore, registration for CAHPS for the MIPS survey could be an optional or mandatory requirement for them.
| Reporting via (QPP Program) | Participating as | Registration is Optional | Registration is Required |
| APM Performance Pathway (APP) | Groups | ❌ | ✔️ |
| APM Entities | |||
| Traditional MIPS | Groups | ✔️ | ❌ |
| Virtual groups | |||
| APM Entities | |||
| MIPS Value Pathways (MVPs) | Groups | ✔️ | ❌ |
| Virtual groups | |||
| APM Entities |
The aforementioned table clarifies that CAHPS is optional for groups, virtual groups, and APM Entities in MVPs and Traditional MIPS.
For Traditional MIPS, participants have to report 6 quality measures for MIPS 2023 performance year. Here CHAPS acts as a collection type. So, a participant is free to choose the collection type accordingly. They can either use one for all quality measures reporting or select different for all of them. We can say that the CAHPS for MIPS survey in Traditional MIPS satisfies the part of obligations for IA_BE_6. Here IA_BE_6 denotes the ‘Regularly Assess Patient Experience of Care and Follow Up on Findings’ improvement activity’.
Similarly, those participating in QPP MIPS Value Pathways have a choice of using CAHPS for reporting at least 1 of the 4 quality measures reporting. One thing, one must keep in mind is that CAHPS for MIPS survey registration must be done on time. Anyhow, Shared Savings Program ACOs are free from any hassle of prior registration throughout.
MIPS Reporting Policy Guide for Shared Savings Program ACOs
It’s a necessary condition for Shared Savings Program ACOs to report via Advanced Performance Pathway (APP). So, if this happens, they do not necessarily need to register for CAHPS. They will automatically get registration as APP participants. Anyhow, they must have a CMS-approved survey vendor for the administration of CAHPS for MIPS 2023 reporting.
However, the rules for groups participating in the Shared Savings Program ACO are slightly different. They might register for CAHPS for MIPS Reporting if they have determined to perform surveys as a group. In addition to submitting the CAHPS Survey as an ACO via the APP, the group would also participate in the survey.
Registration for CAHPS for MIPS Survey
- Registration Period
The registrations for CAHPS Survey have been done between April 1 to June 30, 2022, for MIPS Reporting in PY 2022. For MIPS 2023, we have a different registration starting date. CAHPS registration will commence on April 3. And, the deadline for ending the registration process is June 30, 2023. So, QPP MIPS requires all CAHPS registration to be done before that. QPP MIPS will not favor anyone for the delay and the portal will be closed at 8 p.m. ET.
- How to Register?
[Note: A participant applying for CAHPS Registration must have Security Official role for their facility]
- First of all, sign in to Quality Payment Program’s portal
- Navigate to the Manage Access page.
- Choose “Edit Registration.”
Once the registration process completes, CMS provides instructions for authorizing CMS-approved vendors. These vendors administer the CAHPS survey for you in MIPS reporting.
CAHPS Registration Cancelation Procedure
A participant can have many reasons for cancelation of CAHPS registration from their side. One must be that you haven’t planned to use CAHPS for MIPS Survey for the MIPS reporting in PY 2023. Therefore, you must cancel your registration by June 30, 2023. Again, you need a Security Official role for your facility to complete the registration cancellation process.
- Go to qpp.cms.gov and log in
- Go to Manage Access.
- Pending requests in your queue might be approved or denied.
- Cancel your registration.
Conclusion
CMS has finalized the dates for initiation and closure of CAHPS for MIPS Survey for MIPS 2023 reporting. This time, participants have only five collections type available for quality measures reporting. CMS Web Interface is now reserved for Shared Savings Program ACOs for MIPS reporting via the APP. If you have planned to utilize these surveys for MIPS 2023 reporting, get ready to register for it.
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