The following blog post was written by Susan Maxsween, Vice President of Healthcare Operations & Consulting at RMS.

MIPS QPP Improvement Activities

Positioning your practice to succeed in our ever-changing landscape of patient care delivery is vitally important. One means to achieve alignment with MIPS quality improvement activities is to attest to patient satisfaction surveying. This is an activity that you may already be doing. Many practices already measure patient experience through surveys. Now this activity can be used to earn MIPS points.

If you have questions about the Merit-based incentive Payment System (MIPS), we’ve got you covered! With the implementation of the incentive program, referred to as the Quality Payment Program (QPP), eligible clinicians are now required to demonstrate evidence of quality in patient care delivery and in doing so, are now entitled to enhanced payment from CMS. The program is designed to reward value and outcomes in four areas: quality, improvement activities, promoting interoperability, and cost.

MIPS improvement activities

The newest addition to the value outcome measures is “Improvement Activities” (IA). This category includes evidence of activities that assess how practices improve care processes, demonstrating evidence of patient engagement in care, and increase access to care. Activities can be chosen based upon your practice’s strengths. Practices can pick and choose these performance measures based upon practice specifics such as location and size. To receive points for patient satisfaction surveying under the MIPS QPP, eligible clinicians or groups are required to attest to some of the following Improvement Activities:

  • 1A_BE_6 – Collection and follow-up on patient experience and satisfaction data on beneficiary engagement. This activity must be administered by a third-party survey vendor.
  • 1A_PSPA_17 – Implementation of analytic capabilities to manage total cost of care for practice population. This measure should be administered by a third-party survey vendor.
  • 1A_PSPA_19 – Implementation of formal quality improvement methods, practice changes, or other practice improvement processes. This measure should be administered by a third-party vendor.
  • 1A_PSPA_11 – Participation in CAHPS or other supplemental questionnaires. This measure should be administered by a third-party vendor.
  • 1A_BE_13 – Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms. This measure must be administered independently to the best extent possible.

You may be asking, what does this mean to me? It means that you can receive points under the MIPS QPP by attesting to a minimum 90-day period of engaging your patients through administration of a satisfaction survey, including proof of meeting a number of the above Improvement Activities. Moreover, attesting to these Improvement Activities facilitates interactions between you and your patients, providing valuable information to transform operations. It is a win-win situation all around.

MIPS scoring points

What will you need to receive points under the MIPS QPP? The criteria to attest is relatively short:

  • You’ll need a minimum of 90 days of collected patient survey response data in a database that can be analyzed and benchmarked.
  • You’ll need a standard patient satisfaction survey, like the CG-CAHPS® Tool Version 3.0.
  • You’ll need a defined, ongoing patient survey process (it is recommended that a third-party survey vendor conducts this fieldwork).
  • You’ll need to demonstrate that the practice is reviewing the patient survey findings and building improvement activities based upon the findings.

MIPS requirements

Earning MIPS QPP points is easy if your practice meets the criteria.

Let us help you assess whether or not you qualify for earning these patient satisfaction survey MIPS QPP points. RMS is an approved CMS CAHPS® vendor with significant experience and expertise in patient surveying. We understand your patient’s experience is important to you. We also appreciate that your goal is to make a significant difference in your patient’s experience by implementing and managing improvement activities as they align with your annual MIPS quality improvement reporting.

What sets us apart from other patient surveying firms is our approach in customizing the survey to suit a client’s needs while maximizing response rate and satisfaction scores. We utilize various survey modalities, including phone, mail, email and texting options to obtain valuable patient feedback. The RMS team works with its clients to determine the best approach to patient experience surveying for their organization. We can also customize survey questioning to focus on value areas, such as use of a patient portal.

Our clients typically experience high survey response rates above national averages. RMS also provides promotional and informational collateral materials to clients, which can be posted in the facility and given to patients at the time of discharge reminding them to participate in the survey. The goal is to build both staff and patient awareness and engagement of the survey process.

RMS is a full-service research and consulting firm located near Syracuse, New York.  If you are interested in learning more about our CG CAHPS for MIPS capabilities, please contact Sandy Baker, Vice President of Corporate Development at or by calling 866.567.5422.