Do Not Miss This MIPS Reporting Deadline

MIPS 2017

View up-to-date information on our MIPS resource page here!

Avoiding A MIPS Negative Payment Adjustment

October 2nd marks the very last day for eligible clinicians to start collecting MIPS data for partial year submission. If this fall reporting deadline is missed, clinicians and/or groups will not be eligible to receive a positive payment adjustment in 2019. Rather, they will be faced with two outcomes:

  1. Submit the minimum amount of data and receive a neutral payment adjustment
  2. Submit no data and receive a downward payment adjustment (up to -4%)

Given the flexibility of the MIPS program this year, it would be a missed opportunity for groups and clinicians to submit just 90-days of performance data to Medicare to earn a moderate positive payment adjustment – maybe even the max adjustment – in 2019. Learn more about MIPS and “Pick Your Pace” here.

MIPS Pick Your Pace

While it might seem a bit daunting if you haven’t started, there is still a short window of time for you and/or your group to select the required number of measures and get up and running before the partial submission deadline passes.

Partial Submission Pace

In order to participate in the ‘partial submission’ pace as outlined by the Centers for Medicare and Medicaid Services, eligible clinicians and groups will need to submit 90 consecutive days worth of performance data to Medicare across the following MIPS scoring categories:

  • Quality Category: 6 Measures
  • Advancing Care Information: 9 measures
  • Improvement Activities: a combination of measures totaling 40 points

For clinicians in rural or health professional shortage areas, or for those clinicians considered non-patient facing or “hospital-based,” you may face reduced reporting requirements. Learn more about these special status groups under MIPS here.

Selecting A Submission Mechanism and Measures

Submission methods may vary based on the measure.

MIPS Submission Methods
Meeting Measures with SurveyVitals

Finally, SurveyVitals can help you meet a number of measures in the Improvement Activities category, including a high-weight activity. Additionally, SurveyVitals can submit data to your QCDR and help you administer CAHPS for MIPS. Want to learn more about meeting MIPS measures with SurveyVitals? Contact us at

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September 15th, 2017 Categories: Anesthesia, featured, MIPS Information, Outpatient Practice

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8 Takeaways from CMS Proposed Rule for Changes to MIPS in 2018

MIPS Year 2 Proposed Rule

View up-to-date information on our MIPS resource page here!

Ready or not: MIPS 2018 Proposed Rule

Not fully prepared for MIPS and feeling slightly overwhelmed? You’re not alone. According to a recent report, only 8 percent of physicians feel highly knowledgeable about the MIPS program halfway through the first performance year. Even more concerning, a reported 41 percent of physicians interviewed had never even heard of MACRA or the MIPS program. Which is why it might surprise you that the Centers for Medicare and Medicaid Services (CMS) already released a long list of changes in the proposed rule for MIPS 2018.

However, most clinicians will likely be relieved to learn of the new changes. With most of the changes aimed at aiding small practices, many of which have been struggling to adjust to the transition. CMS also opted to loosen some reporting restrictions and provide for new modes of participation in the proposed rule.

So what exactly can you expect heading into MIPS 2018? Checkout our wrap-up of key takeaways from the Proposed Rule:

1. Small practices will see some of the biggest changes

Small practices will be the most affected by the proposed changes. CMS is seeking to expand the number of clinicians who will be exempt from MIPS 2018 by increasing the low-volume threshold. In 2017, clinicians that bill Medicare Part B more than $30,000 in allowed charges per year or provide care for more than 100 unique Medicare patients annually are eligible to participate. In 2018, however, the number of clinicians exempt from MIPS will increase. The new threshold will jump to $90,000 in Part B payments or 200 unique Medicare patients annually.

2. Performance Period Adjustments

CMS is lengthening the performance period for the Quality and Cost categories from 90 days in 2017 to the full year in MIPS 2018, though CMS will not use the Cost performance scores for final score determination. For the Improvement Activities and Advancing Care Information (ACI) categories, however, the 90-day performance period will remain the same.

3. Clinicians will have the option to join Virtual Groups

Virtual groups are new to the MIPS 2018 program year. A Virtual Group is defined as a combination of 2 or more TINS who choose to participate together in MIPS. Virtual Groups have the flexibility to work with other groups or types of practices from any location. This could open the door for more clinicians to join the program and work with their peers, regardless of their geographical proximity. Learn more about Virtual Groups.

4. Small Practice Bonus

Small practices of 15 or fewer clinicians will be eligible to receive a Small Practice Bonus under the proposed rule. This bonus would add five points to a group’s score to help them meet MIPS requirements, as long as they submit data on at least one performance category in an applicable performance period.

5. Complex Care Bonus

Clinicians who provide medically complex care could be eligible to receive an adjustment by adding the average Hierarchical Conditions Category (HCC) risk score to their final MIPS 2018 score. Generally, this award would be between 1 to 3 points, based on the complexity of care provided, as determined by CMS.

6. EHR Requirements Slowed

In another reversal, CMS will allow the continued use of the 2014-edition Certified Electronic Health Record Technology in MIPS 2018, which was set to be phased out. This again is aimed at easing the burden for practices that are struggling to keep up with all the changes. Currently, many practices don’t have the resources or access to the 2015 CEHRT, which makes the transition very difficult. To encourage use of new EHR technology, CMS has proposed a scoring bonus for practices that use 2015 Edition CEHRT exclusively.

7. New Scoring Options for Facility-Based Physicians

Facility-based physicians, such as hospitalists, will have the option to use facility-based scoring for reporting. A facility-based clinician is defined as a clinician who provides at least 75 percent of their services in an inpatient hospital or emergency room setting. This includes many anesthesiologists and nurse anesthetists. Facility-based groups are defined as groups in which at least 75 percent of the individuals are facility-based clinicians. CMS hopes to align facility-based scoring with the Hospital Value-Based Purchasing (VBP) Program. The total performance score for the hospital VBP measure set would be applied to a clinician’s Quality and Cost performance categories.

8. Multiple reporting mechanisms per category allowed

For the first program year, CMS stipulated that for clinicians participating in MIPS, only one reporting mechanism is allowed per performance category (i.e. if a clinician is using a QCDR to report on a measure in the quality category, all measures in the quality category must be reported via QCDR). The Proposed Rule does away with this requirement and allows clinicians and groups to use whatever combination of reporting mechanisms that best suits their needs, regardless of category.

It is important to note that these changes to the MIPS program for 2018 are proposed changes. As a part of the federal rulemaking process, CMS is currently soliciting feedback from stakeholders and will issue a final rule in the coming months, which could include changes. Stay tuned!

To explore the proposed changes in depth, read the proposed rule here or checkout the CMS fact sheet.

Interested in learning more about SurveyVitals? Click here to sign-up for a free, no hassle product.

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July 27th, 2017 Categories: Anesthesia, featured, MIPS Information, Outpatient Practice


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Featured Article: Measuring the Patient Experience Digitally & Why It Matters

Looking at phone

SurveyVitals CEO Bob Vosburgh shares his perspective on the many reasons to consider patient opinion, beyond reimbursement, in a new article featured in the Anesthesia Business Consultants latest issue of the Communique.

Beyond CAHPS: Measuring the Patient Experience Digitally and Why It Matters By Bob Vosburgh, President, SurveyVitals

Here’s an excerpt:

“For every patient who expresses dissatisfaction or voices concern, there are nine or ten more who keep quiet. However, dissatisfied patients are often some of the most vocal. They are likely to tell at least 20 people about their experiences or go to an online review site.

Why does this matter? Aside from the potential impact on a provider’s reputation, patients who rate practitioners’ bedside manner the worst are far more likely to bring a malpractice suit…”

Read the full article here.

Be sure to let us know what you think in the comments section and share the article with your friends and colleagues.

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September 14th, 2016 Categories: Anesthesia, CAHPS Surveys, featured, Patient Experience, Press Release

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Nurses Rate the Highest in These 3 Areas

Nurse Communicating With Patient
It is National Nurses Day!

To celebrate, we wanted to highlight what makes nurses so special! Using data from 96,571 SurveyVitals® patient satisfaction surveys received in 2016, we examined nurses’ top scoring areas among patients.

Check out our lists for both the Anesthesia Patient Satisfaction Questionnaire (APSQ) and the Standard Patient Satisfaction Questionnaire (SPSQ).

Anesthesia APSQ

1. Ensure Comfort

Patients rated nurses highest when it came to ensuring their comfort during the surgical experience.

2. Decision Prep

Patients consistently said nurses helped them make more informed decisions about their care.

3. Privacy Respected

Nurses scored well among patients for keeping their health information confidential and providing a sense of privacy in the exam room and beyond.

Outpatient SPSQ

1. Courtesy

Patients most frequently said nurses were courteous, rating this attribute highest when compared to other areas of the provider-patient relationship.

2. Confidence

Patients felt confident in their nurses’ abilities, consistently giving high scores in this area.

3. Sensitivity

Nurses scored well among patients for showing sensitivity to their needs and actively listening.

*Results derived using mean scores from 87,318 completed Anesthesia nurse anesthetist surveys and 9,253 completed Outpatient nurses surveys. Data collected between January 1, 2016, through May 1, 2016.

What do you think? Is this consistent with your patient feedback scores? Share this article and join the conversation using the hashtag #NationalNursesDay.

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May 6th, 2016 Categories: Ambulatory and Outpatient Surgery, Anesthesia, featured, Outpatient Practice, Patient Experience

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To GPRO, or not to GPRO, that is the question for anesthesiology providers

GPRO SurveyVitals

By now, everyone understands that physicians who don’t report adequate quality measures in 2015 will see a 2% penalty in 2017. There are still questions, however, about the best way to report your quality data to CMS, especially for anesthesiology providers. And while the date to adjust your 2015 reporting mechanism has passed, we’d like to share some information as you start thinking about your plan for 2016.

At the highest level, you must decide whether to report as an individual EP (Eligible Provider) or as part of a group. There are pros and cons to each, although SurveyVitals® recommends the individual EP route. Among other reasons, this option allows you to submit quality data through a QCDR (Qualified Clinical Data Registry).

GPRO, the Group Practice Reporting Option, is another method to submit your quality data, but has numerous CMS requirements. Here are a few things we’d like our clients to know about GPRO:

  • GPRO is optional.
  • GPRO only applies to EPs with a common Tax Identification Number (TIN).
  • If you chose a GPRO reporting method, the decision is irreversible for 2015 (the deadline was June 30, 2015).
  • You cannot submit your data through a QCDR if you choose GPRO.
  • If you choose GPRO and have 100 or more EPs (25 or more for 2016), you’ll be required to run the CAHPS for PQRS survey. The survey is optional in 2015 for groups of 2-99 EPs.
    • The survey is tailored to primary care, which does not help anesthesiology providers.
    • The survey will not be paid for or administered by CMS. Participating groups will be required to contract with a CMS-certified vendor to administer the CAHPS for PQRS survey.
    • The CAHPS for PQRS survey will be administered on paper with live phone follow-ups for non-responders. Surveys sent via email or text message aren’t allowed at this time, which makes improvement based on real-time feedback virtually impossible. This is why SurveyVitals is not a CMS-certified vendor.
  • By reporting via GPRO, you’re agreeing to have your PQRS performance results publicly posted on the Physician Compare website. The performance rates will apply to the entire group.

Choosing whether to report quality measures as a group or by individual can be a complicated decision when you factor in eligibility and reporting requirements, and here’s why we recommend individual reporting:

  • Individual EPs can submit through QCDRs:
    • QCDRs can focus on more relevant, anesthesia-specific quality measures.
    • The QCDR collects data for the purpose of providing improved quality of care for patients.
    • There is greater potential to meet the reporting requirement of 9 measures across 3 National Quality Strategy domains.
    • The QCDR typically submits data to CMS on your behalf.
    • As the ASA said on its website, “Participation in [the] ASA QCDR not only helps protect a practice’s income, but it also helps keep money in the practice so you can continue your focus on patient safety.

As we announced earlier this year, our Anesthesia Patient Satisfaction Questionnaire, the APSQ, fulfills measure #16 for NACOR, the Composite Patient Experience, and counts as an outcome measure as well. We’re also working to get a patient satisfaction measure included in other QCDRs like ABG and ASPIRE for 2016. We expect that list will continue to grow, so contact us if you’d like additional information on the measures SurveyVitals can help you meet for each QCDR.

If you don’t report through a QCDR, it is still beneficial to report individually since the measures that must be reported to CMS are the same. Although some variations exist in the methods (for 2015, claims-based for individual reporting and web interface for GPRO 25+ EPs), you can avoid the CAHPS for PQRS survey requirement and its expense. Additionally, the Value-Based Payment Modifier (VM) is not affected by reporting individually since the VM is calculated by TIN.

SurveyVitals will attempt to stay on top of these ever changing requirements in order to provide the most value to our clients. Stay tuned for more!

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October 7th, 2015 Categories: Anesthesia, CAHPS Surveys, featured, MIPS Information

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Press Release – 1 million anesthesia surveys

1 million surveys completed

1 million anesthesia surveys

SurveyVitals® just reached a huge milestone! An anonymous patient completed the 1 millionth anesthesia patient satisfaction survey yesterday morning (August 18, 2015). SurveyVitals prides itself on providing actionable, accurate data, and the value of our national baseline continues to expand with each new survey that is completed. Benchmark your practice, divisions, and physicians against a national, organization, division, or specialty baseline.

We continue to disrupt the outdated model of expensive paper surveys that garner low response rates and provide delayed feedback. We’re proud to say our solution is used by thousands of providers across 58 specialties, and that by first quarter of 2016 we should have 1.5 million surveys in our anesthesia baseline and another 1 million in our outpatient baseline. Here’s to patient satisfaction, quality, and improvement!

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August 19th, 2015 Categories: Anesthesia, featured, Press Release

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Our Clients – Central Wisconsin Anesthesiology

Central Wisconsin Anesthesiology

We always enjoy bringing new clients on board, but some are just so much fun! It was great to hear Central Wisconsin Anesthesiology felt the same way! Here’s what Michelle Theiler, their Human Resources and Operations Supervisor, recently said about their experience:

“Our board voted to implement SurveyVitals, an experiential survey solution for continuous improvement. I can’t say enough about the professionalism and talent of the SurveyVitals team. Their team members are all very professional, knowledgeable, have excellent communication skills, and their level of commitment to the product is exceptional. Within one month, we were able to implement the SurveyVitals solution. SurveyVitals’ fun, dedicated approach to quality customer service far exceeded our expectations. I want to especially recognize PJ, Ben, Tracy, and Heather for “going the extra mile” to ensure our satisfaction. Great job, SurveyVitals!”

Thanks for the shout out, Michelle! We’re glad to have made onboarding a great experience for you, and look forward to helping you gather patient feedback for years to come.

August 17th, 2015 Categories: Anesthesia, Client Spotlight, featured


Best Practice – Business card with personal cell phone number

Dr. John Dalton

Dr. John Dalton, Chief Quality Officer of PhyMed Healthcare Group, has a unique approach to providing top quality patient care. At the end of each visit, he hands the patient his business card. Not such an unusual practice, until the patient notices that he’s included his personal, private mobile phone number on the card. Dr. Dalton believes giving patients access to their providers is important. “Patients should be able to reach a real person when they need help. Otherwise, we’re no better than the cable company.”

Some providers may be concerned about a deluge of patient calls, but Dr. Dalton has only received a handful calls in more than two years. However, the mere act of being available reassures patients of his interest in their wellbeing and his commitment to quality. He’s seen the success of this approach reflected in improved patient satisfaction scores.

Have a tip to share with your colleagues? Submit your best practice, and you may see it featured in the next newsletter.

July 13th, 2015 Categories: Anesthesia, Best Practices, Client Spotlight


Our Clients – Allied Anesthesia

We always appreciate working with clients who get quality and continuous improvement. Here’s what one of our clients said:

“We believe that by providing our patients the option to give feedback about their experience, we can improve our quality of care, and better understand the experience from a different perspective. Further, we can learn from other comments that may or may not relate to anesthesiology, but rather privacy or clarity of information. The feedback helps make us aware of what we can keep in mind during our interactions with our patients.”

Allied Anesthesia Logo

Read the full article at their website.

Thanks to everyone at Allied Anesthesia in Santa Ana, CA for making patient satisfaction a priority. Our hats are off to you!

July 13th, 2015 Categories: Anesthesia, Client Spotlight, featured

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