Skip to main content
Request a demo

CAHPS for MIPS 101: What this patient experience survey means for healthcare clinicians and providers

Co-authored by Adam Higman, Payer Consulting

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for Merit-Based Incentive Payment Systems (MIPS) Survey—also known as MIPS CAHPS—was developed by the Centers for Medicare & Medicaid Services. This survey measures patient experience with clinicians participating in MIPS, one track of the Quality Payment Program (QPP) in which healthcare providers can receive performance-based Medicare payment adjustments. CAHPS for MIPS survey results are publicly reported on the Care Compare website.

If you’re a clinician or operate a healthcare practice, it’s important to understand the basics of this survey and how to get started.

What are CAHPS for MIPS surveys?

The CAHPS for MIPS Survey collects feedback from patients about their experience with their primary healthcare provider and visits to medical practices. Survey data serves to help patients compare care providers while incentivizing practices to improve care.

Is participation in the MIPS CAHPS Survey mandatory?

Only Accountable Care Organizations (ACOs) within the Medicare Shared Savings Program (MSSP) are required to use MIPS CAHPS. Outside of MSSP ACOs, CAHPS for MIPS is a voluntary measure for medical groups participating in the MIPS Program.

The MIPS CAHPS Survey is an optional quality measure survey that groups participating in traditional MIPS and some new MIPS Value Pathways (MVPs) can choose to administer through a CMS-approved vendor, like Press Ganey.

What types of questions does this patient experience survey ask?

The CAHPS for MIPS Survey asks patients 59 questions about their care over the past six months. The questions cover topics such as:

Who receives the CAHPS for MIPS Survey?

CMS selects a random sample of up to 860 fee-for-service Medicare beneficiaries (patients) who received primary care within the medical group or ACO. The sample is limited to patients age 18 or older who visited the group or ACO for primary care at least twice.

Those 18 and older who visited the group or ACO for primary care at least twice are eligible to take the survey. Sample size depends on the number of group/ACO clinicians and beneficiaries.

How do I administer the MIPS CAHPS Survey?

Groups that are using the MIPS CAHPS survey voluntarily as part of the MIPS Program must register to participate in CAHPS for MIPS through the CMS Registration System. ACOs in the MSSP don’t need to register, as they’re automatically registered to use the survey through their participation in MSSP. All ACOs and medical groups must contract with a CMS-approved survey vendor to conduct the survey.

The official CAHPS for MIPS Survey is conducted by CMS-approved survey vendors, like Press Ganey, once per year over a four-month period. Respondents are surveyed by mail with phone call follow-up.

Why is this patient experience survey important for healthcare clinicians and providers?

Survey feedback helps primary care providers receive performance-based Medicare payment adjustments and understand opportunities to improve care delivery. The provider’s score indicates whether they’re eligible for payment adjustments, with better scores indicating that high-quality care has been provided.

How do CAHPS for MIPS Surveys benefit patients?

MIPS CAHPS Surveys give patients the opportunity to provide feedback to their primary care physicians about various aspects of the patient experience. Since results from these surveys are publicly reported, patients can make informed decisions when selecting a physician. In turn, these insights help organizations better address patient needs.

How do CAHPS for MIPS Surveys improve healthcare delivery?

Collecting patient experience feedback gives primary care providers important insights. Key decision-makers can leverage this information to identify service recovery gaps and develop specific improvement strategies. Press Ganey offers benchmarks, patient experience consulting services, and more tools to ensure success.

How can my organization get started with CAHPS for MIPS surveys?

Healthcare organizations that choose to administer the CAHPs for MIPS Survey should consult a CMS-approved survey vendor, such as Press Ganey, to implement the survey and help leaders stay up to date on all associated requirements. Press Ganey also offers continuous patient experience insights through flexible outreach options, consulting solutions, industry-leading expertise, and compliance management to assist participating sites in adhering to survey requirements.

The MIPS CAHPS Survey is a valuable measurement tool for CMS and your organization to gauge the experiences of patients with primary care providers. To ensure your organization complies with CMS requirements, it’s critical to understand the basics of the survey program, how to implement the survey, and benefits of partnering with Press Ganey to administer the CAHPS for MIPS Survey.

Read more about CAHPS surveys and regulatory offerings or speak with an expert to learn how your organization can best measure patient experience.

About the author

David L. Larsen currently works as Senior Advisor Member Experience at Press Ganey and prior to that he worked as an independent healthcare consultant working with predictive analytics, member engagement, and pharma vendors to improve their offerings and sales approach to managed care plans and working with managed care plans to improve their Medicare Advantage Star Ratings focusing on improvements related to CAHPS, HOS, HEDIS, medication adherence, and member experience measures. David served as the Director of Quality Improvement for SelectHealth in Salt La­ke City, Utah for 32 years and worked for Intermountain Healthcare for 38 years. SelectHealth is a mixed model HMO with more than 950,000 members in Utah, Idaho, and Nevada across all insurance product lines including, Medicare Advantage, manage Medicaid, large, small, and individual commercial plans, and ACA plans. Intermountain Healthcare is an integrated health care delivery system with 23 hospitals and over 1,500 employed physicians. As the Director of Quality Improvement, David had responsibilities for oversight of the Medicare Advantage Stars program for which SelectHealth received a 5 Star rating in 2022, maintaining NCQA accreditation; HEDIS performance measurement and improvement; CAHPS and HOS measurement and improvement, public reporting (transparency), and population health. David has also been responsible for the oversight and development of chronic disease registries, performance measurement and web based reporting systems, quality improvement pay for performance incentives for providers, provider transparency programs, and direct patient improvement interventions related to chronic illnesses including patient adherence monitoring, reminders, and incentive programs.

Profile Photo of David Larsen