CMS Requrements for Patient Surveys

CMS Requrements for Patient Surveys

Ambulatory Strategies Inc.
[email protected]


I heard about a new Medicare requirement for patient surveys. True? And, are there new quality measures CMS is requiring we report this year?


The Centers for Medicare and Medicaid Services (CMS) requires surgery centers participate in the OAS CAHPS survey beginning January 1, 2018 and you will need to act this year to be ready.

The OAS CAHPS stands for Outpatient and Ambulatory Services (OAS) Consumer Assessment of Health Providers and Systems (CAHPS).

If you do not participate in the OAS CAHPS survey beginning January 1, 2018 or report other program measures, your surgery center is subject to a 2% reduction in Medicare reimbursement. This 2% reduction is effective if you fail to participate in any program measures including the ones reported via claims (e.g., wrong site/wrong procedure/wrong implant, burn, fall, antibiotic timing, hospital transfer, commonly known as G codes submitted on billing claims for the procedure performed), via Quality Net (e.g., safe surgery checklist, volume information, GI frequency/medical necessity), and via National Healthcare Safety Network (NHSN) for flu vaccine participation. The 2% reduction is based on participation in all these reporting programs and it is not a 2% reduction for each one in which you fail to participate. Failure to report the data required in 2017 will result in a 2% reduction in payments for fiscal year 2019. And, failure to add the 2018 implementation of the OAS CAHPS survey will result in payment reduction in fiscal year 2020.

Other changes on the horizon include a change in deadlines for reporting. All data collected in 2016 for reporting in 2017 must be reported between January 1 – August 15, 2017. All data collected in 2017 for reporting in 2018 must be reported between January and May 15, 2018.

If your surgery center has less than 240 Medicare primary and secondary claims in the year prior to the data collection period, you are exempt from participation in the reporting and survey program.

Patient Experience Survey:

For the OAS CAHPS, sometimes called Patient Experience Survey, a surgery center must contract with a CMS approved vendor which will administer the survey. The surgery center will be required to provide demographic information to the contracted vendor which will determine which patients will receive surveys. The CMS rules state some patients are to be exempted from selection to receive a questionnaire, such as patients under 18 years of age, persons going to nursing homes, persons in hospice care and a few other qualifiers. Three hundred surveys must be completed; therefore, the vendor may have to contact a thousand or so of your patients throughout the year to obtain 300 completed surveys. The vendor is the one who chooses which patients receive the survey and how the sample is selected throughout the year to achieve the 300 completed surveys.

The OAS CAHPS survey, which is 37 questions long, must be conducted by the vendor via mail or phone interview, not by email. To read the survey that will be conducted by phone, which is a set script, go to, then select the “CATI questionnaire”. To read the survey that will be mailed, go to the same link and select “mail questionnaire”.

CMS requires that the approved survey vendors submit the 300 completed survey responses to CMS. Eventually, the results will be posted by CMS on a web page so patients can compare responses among surgery centers and hospital outpatient departments.  

Some surgery centers that have started the survey and some who are interviewing vendors report that each survey is costing $10-$30. Some vendors want a contract to survey all your patients using the 37-question survey tool, which can be cost prohibitive. Some will survey your patients to reach the 300 participants required by CMS and survey your other patients using their normal patient questionnaire with fewer questions. And some will survey enough of your patients to achieve the 300 completed surveys while letting you handle your own patient satisfaction questionnaires in ways you have in the past, such as via paper or email.

To see the CMS approved vendors, go to: If you belong to a GPO, you will want to check which CMS approved vendors are available through the GPO. However, shop around since all approved vendors are not aligned with a GPO and you may get better pricing outside of the GPO.

Significant lead time is required to establish this process since your selected vendor must have its IT software communicate with your IT software to transmit your patients’ demographic information, including the patients’ telephone and mailing addresses, to allow the vendor to select and contact the sample of patients per CMS rules.

Quality Measures Reporting:

In 2018, CMS will add two other program measures that will be reported via Quality Net online data submission tool: (1) Normothermia Outcome which requires information about patient temperature checks following 60 minutes of general anesthesia and (2) Unplanned Anterior Vitrectomy which will measure the frequency of the procedure following cataract surgery. Some surgery centers are tracking that information now as a “trial run” in preparation for reporting in 2018.

Added this year is data on hospital visits following an outpatient colonoscopy. This data will be gathered by a company extracting claims history and does not require action on your part.

The following is a summary of all reporting requirements for 2017 and 2018, including ones reported via

  • flu vaccine reported on NHSN,
  • G-codes reported on your claims,
  • data extrapolated by others on claims submitted,
  • beginning in 2018, the last five, numbered ASC-15a through ASC-15e (these are grouped questions on the OAS CAHPS patient experience questionnaire reported by the CMS approved vendor).