Important Update for Ambulatory Surgery Centers Nationwide – Mandatory OAS CAHPS Survey in 2025
Updated August 8, 2024
On the heels of the Quarterly Membership Meeting of the New Jersey Association of Ambulatory Surgery Centers (NJAASC) at which Brach Eichler provided a legal report on the latest state and federal legal matters, it is crucial for all non-exempt Medicare-certified ambulatory surgery centers (ASCs) to be aware of the upcoming changes regarding the Center for Medicare & Medicaid Services (CMS) Outpatient and Ambulatory Surgery (OAS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (OAS CAHPS survey).[1]
Mandatory Implementation in 2025
Currently, participation in the OAS CAHPS survey is voluntary. However, starting in 2025, it will become mandatory for all non-exempt ASCs. The OAS CAHPS survey collects information about patients’ experiences in Medicare-certified hospital outpatient departments (HOPDs) and ASCs. It is designed to measure the quality of patient experiences in these settings to aid in quality improvement and provide comparative consumer information about outpatient facilities.
Survey Details and CMS-Approved Vendors
The OAS CAHPS survey covers various aspects of patient experience, including preparation for surgery or procedures, check-in processes, facility cleanliness, communication with staff, discharge procedures, and preparation for recovery at home. It also inquires whether patients received information on managing potential side effects during recovery. The survey is intended for fee-for-service Medicare patients 18 years and older who have undergone medically necessary or elective surgeries or procedures.
The list of CMS-approved vendors offering the OAS CAHPS survey[2] is available on the CMS website.[3]
Voluntary Submission in 2024
In 2024, ASCs may choose to voluntarily submit OAS CAHPS data. This period offers an opportunity to familiarize with the survey process before it becomes mandatory.
Impact on Reimbursements
Beginning in 2025, ASCs must conduct and submit the OAS CAHPS survey as part of their quality reporting requirements. Non-compliance will result in a 2.0 percentage point reduction in the annual fee schedule update for HOPDs or ASCs that fail to meet this requirement. Therefore, it is imperative to develop a plan and train medical and operational staff on how to effectively approach patients and encourage survey participation.
Public Reporting of Survey Results
The OAS CAHPS survey results[4] for both HOPDs and ASCs will be accessible on the Data Catalog at Data.CMS.gov. Additionally, these results will be publicly reported on the Compare Tool[5] at Medicare.gov, starting in 2025 for HOPDs, and 2026 for ASCs.
Exemptions
Medicare-certified hospitals and ASCs that treat fewer than 60 survey-eligible patients in the year preceding the data collection period have the option to submit a request for exemption from participating in the OAS CAHPS Survey. The Participation Exemption Request (PER)[6] form (and related worksheet) is available on the OAS CAHPS website and in Appendix R of the Protocols Guidelines Manual.[7] The PER submission is required during the mandatory submission period but not currently.
An additional exemption applies for ASCs that had fewer than 240 fee-for-service Medicare claims[8] (FFS Medicare primary and secondary payer, which excludes Medicare Advantage plans) in the year prior to the data collection year for the applicable payment determination for the same time period. ASCs will not be required to submit a participation exemption request form for the OAS CAHPS Survey for the same time period.
ASCs are encouraged to take proactive steps now and select a CMS-approved vendor to ensure compliance with the upcoming mandatory OAS CAHPS survey requirements and to maintain their quality reporting standards. For additional information about the OAS CAHPS survey requirements or any other healthcare related questions, please contact Isabelle Bibet-Kalinyak, Esq., Vice Chair Healthcare Practice Group & Partner, Brach Eichler L.L.C. at (330) 554-4133 or IBK@BrachEichler.com
[1] https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/outpatient-and-ambulatory-surgery-cahps
[2] https://oascahps.org/General-Information/Approved-Survey-Vendors
[3] https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/outpatient-and-ambulatory-surgery-cahps
[4] https://data.cms.gov/provider-data/dataset/48nr-hqxx
[5] https://www.medicare.gov/care-compare/
[6] https://oascahps.org/For-Facilities/Participation-Exemption-Request
[7]https://oascahps.org/Portals/0/SurveyMaterials/V8.1_OASCAHPS_ProtocolsGuidelinesManual.pdf
[8] Place of Service Code 24, Ambulatory Surgical Center, defined as a “freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.”
Isabelle Bibet-Kalinyak
Member
Healthcare Law
973.403.3131 · 973.618.5531 Fax
ibibetkalinyak@bracheichler.com
Related Practices: Healthcare Law
Related Attorney: Isabelle Bibet-Kalinyak
Related Industry: Healthcare
