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FAQS FOR PRACTICES

Participation

What are the practice requirements for PECS?

Please refer to Section 7.04 of the PCF Participation Agreement: Section 7.04 Patient Experience of Care Measure:

a. The PCF Practice shall procure a CMS-approved vendor to conduct the Consumer Assessment of Healthcare Providers & Systems (CAHPS®), also known as the Patient Experience of Care Surveys (PECS) ("PECS" hereafter). CMS will notify the PCF Practice at least 120 days in advance of when the PCF Practice must begin conducting PECS, and CMS will make available to the PCF Practice a list of approved PECS vendors on the same date or sooner, in a form and manner to be determined by CMS.

b. The PCF Practice shall:
1. Submit a patient roster for all patients to CMS by a date and in a manner to be specified by CMS. CMS will validate the roster and provide the roster to the survey vendor directly;
2. Pay for the surveys and ensure that the survey results are transmitted to CMS by a date and in a manner to be specified by CMS; and
3. Ensure that the vendor adheres to the questionnaire, survey protocol, and format for submitting PECS results to CMS.

c. If the vendor does not timely submit the PCF Practice's PECS results, or if the vendor submits inaccurate, unusable, or otherwise compromised data, CMS will assign the PCF Practice a 0 for its yearly PECS score, and the PCF Practice will not meet the Quality Gateway for that Performance Year, pursuant to Section 5.03(b)(1), and may take remedial action against the PCF Practice pursuant to Sections 15.01 and 15.02.

What are the practice responsibilities for PECS?

Please see this document, Practice Site Responsibilities for PCF PECS.

Where can I find the list of approved survey vendors?

You can find the list of Approved Survey Vendors here.

When will the approved PCF PECS vendor list be released?

The PCF PECS Vendor Solicitation occurs in January of each Performance Year. The updated vendor list is published in May and can be found here.

How do I register as a practice site user?

Please see this Quick Link, How to Register as a Practice Site User.

How do I register a practice site?

Please see this Quick Link, How to Register a Practice Site.

How do I authorize a survey vendor?

Please see this Quick Link, How to Authorize a Survey Vendor.

How do I delete a vendor authorization?

Please see this Quick Link, How to Delete a Survey Vendor Authorization.

How do I upload a BAA?

Please see this Quick Link, How to upload a BAA.

Does our practice need to authorize a vendor every year?

Once authorization is submitted, it remains valid for the duration of the model, unless the practice site terminates the authorization.

Who pays to administer the CAHPS survey (Patient Experience of Care Survey)?

The PCF PECS protocols follow the same model as other CAHPS surveys, such as the Merit-based Incentive Payment System CAHPS and Accountable Care Organization CAHPS, where providers contract with approved survey vendors for the data collection and implementation of the survey. CMS has adopted standardized survey protocols that allow for varying survey costs and ensured that the approved vendors are trained to implement these protocols consistently. However, CMS does not dictate the pricing for the approved survey vendors. We encourage practices to contact vendors for cost and service information as there may be differences among vendors. The list of CMS-approved survey vendors for the PCF PECS is here.

We already have a BAA with a survey vendor. Can we use that?

Yes, it's possible. Please discuss with your selected survey vendor.

What form does my practice need to submit for the BAA?

More information about Business Associates can be found here. An example BAA can be downloaded from here. Your survey vendor may have a BAA form that they can provide.

Our practice already conducts a patient survey. Can PCF use those data instead?

The PCF PECS, while based on a combination of questions from the CG-CAHPS v.3.0 and CAHPS Patient-Centered Medical Home Item Set v. 3.0., is designed specifically for the PCF Model. PCF practices are required to submit a patient roster for sampling and to engage a vendor for the PCF PEC survey administration as required for the PCF quality reporting.

To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys or census surveys from 4 weeks prior to and during the period when the PCF PECS is actively surveying. CMS-sponsored surveys such as the CAHPS® Survey for Accountable Care Organizations Participating in Medicare Initiatives are exempt from this guidance.

For more information, please reference the resource Responsibilities of Primary Care First (PCF) Practice Sites for the Patient Experience of Care Survey.

If my practice site is in an Accountable Care Organization (ACO) does the CAHPS survey meet the need for the PECS requirement?

Practice sites that are dual participants in an ACO and PCF must meet all quality reporting requirements of the ACO and for PCF. The CAHPS for ACOs survey is part of the ACO quality standard and should be fielded as required. PCF practice sites will also be required to submit a patient roster for sampling and to engage a vendor for the PCF PEC survey administration as required for the PCF quality reporting.

What is the difference between ACO CAHPS and PCF PECS?

ACO CAHPS is based on the Clinician and Group (CG-CAHPS) survey and includes additional program specific survey questions. The PCF PECS, while based on a combination of questions from the CG-CAHPS v.3.0 and CAHPS Patient-Centered Medical Home Item Set v. 3.0., is designed specifically for the PCF Model. Practices that are dual participants in an ACO and PCF must meet all quality reporting requirements of the ACO and for PCF. The CAHPS for ACOs survey is part of the ACO quality standard and should be fielded as required.

Patient overlap between PCF PECS and ACO CAHPS is possible. PCF practice sites must provide a roster of all patients, regardless of payer and/or insurance, who had at least one visit between January 1 and the date of roster submission. Eligible patients are ages 18 and above with addresses in the continental US, including those who live in residential care/assisted living facilities. CMS will select a systematic random sample of patients from each practice site, commensurate with practice site size. To be included in the random sample for the ACO CAHPS survey, assigned Medicare fee-for-service beneficiaries must be 18 years of age or older at the time of the sample draw and non-institutionalized.

To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys or census surveys from 4 weeks prior to and during the period when the PCF PECS is actively surveying. CMS-sponsored surveys such as the CAHPS® Survey for Accountable Care Organizations Participating in Medicare Initiatives are exempt from this guidance. When conducting other surveys, practice sites must not ask any additional survey questions that are the same as or similar to those included in the PCF PECS questionnaire (this guidance does not apply to other CMS-sponsored surveys).

Survey Administration

Why is CMS including a CAHPS/Patient Experience Survey in PCF?

CMS seeks to ensure quality of care, especially the patient experience, is not negatively impacted by PCF's alternative payment model. Patient experience indicates high quality care has been provided according to the patient's own perspective. Positive patient experience is also associated with higher levels of patient adherence, improved clinical outcomes, and lower utilization of inpatient and emergency department services.

Where can I find the survey administration requirements?

The survey administration requirements for the PCF PECS can be found in the Quality Assurance Guidelines.

Where can I find copies of the PCF PECS materials?

All PCF PECS materials, including the mail survey, are posted here on the PCF PECS website for your reference. They are also posted on PCF Connect.

Who can practice sites contact if they have questions about the survey?

Please contact PCF Support via e-mail at PCF@Telligen.com or call 1-888-517-7753. If you have questions related to survey administration, please contact your vendor directly.

My patient has questions, who should they call?

Patients should call the Help Desk using the contact information provided by your survey vendor. This contact information can be found on the questionnaire cover letter, the postcard, the poster, and the waiting room FAQs.

What should we tell our patients about the survey?

Please see the section "Communicate with patients about the survey in accordance with CMS specifications" in this document, Responsibilities of PCF Practice Sites for the Patient Experience of Care Survey (PECS).

How long does the survey take?

The PCF PECS takes about 20 minutes.

When will data collection for the PCF PECS occur?

Data collection occurs in the fall of each performance year.

What are the data collection modes for the PCF PECS?

The PCF PECS is an annual survey conducted once per year. It is a single-phase of data collection. Sampled patients will receive up to 2 mail surveys and 6 telephone calls over the 12-week data collection period.

Can the practice get another poster/another copy of the patient FAQs?

Yes, please go to PCF Connect to download a high-resolution copy of the poster/copy of the patient FAQs to print.

Are there any restrictions on fielding other surveys at the same time as PCF PECS?

To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys or census surveys from 4 weeks prior to and during the period when the PCF PECS is actively surveying. CMS-sponsored surveys such as the CAHPS® Survey for Accountable Care Organizations Participating in Medicare Initiatives are exempt from this guidance. When conducting other surveys, practice sites must not ask any additional survey questions that are the same as or similar to those included in the PCF PECS questionnaire. (This guidance does not apply to other CMS-sponsored surveys). Other surveys can include questions that ask for more in-depth information as long as the questions are different from those included in the PCF PECS.

Sampling

Are all practice sites required to submit a patient roster to CMS?

Yes, each PCF practice is required to submit an individual patient roster to CMS for PECS/CAHPS, even if the practice is part of a larger health care organization with multiple practices participating in PCF.

Why is CMS requesting a roster of our practice site's patients and how will the data be used?

As part of PCF, a CMS-approved survey vendor will administer the PCF PECS to a sample of patients from your practice site. We are requesting your patient roster to select a sample of patients to receive the survey. As you know, measuring and improving patient experience of care is a crucial aspect of PCF. CMS will share the survey results with your practice site to help you make changes to improve your patients' experience of care. In addition, the survey results determine a significant portion of the performance-based adjustment payment (PBA). Without the roster, we will not be able to survey your patients or calculate a PEC survey score for your practice site. If a practice site receives a PECS score of 0, the practice site will not meet the Quality Gateway, and will not be eligible for a positive PBA.

When will the roster information be available?

Roster instructions, templates, and on-demand webinar will be made available to practice sites and HIT/EHR vendors in late spring. You will receive communication about these materials and deadlines via First Edition and Connect.

How do I upload a patient roster?

Practices received the PCF Patient Roster Instructions and Frequently Asked Questions (FAQs) and PCF Patient Survey Roster Template via the First Edition newsletter in May. These materials were posted on PCF Connect. A recorded webinar, Patient Roster Success, was also made available to practices in May. Practices will not submit patient rosters on the PCF PECS website. Rosters will be submitted on the PCF Portal. Practices should contact PCF Support at PCF@Telligen.com or (888) 517-7753 with any questions.

How are patients chosen to receive a PCF PECS? Will all patients receive a survey?

CMS will select a random sample of patients from the rosters submitted by practices. Not all patients will receive a survey. The sample will consist of the following patient specifications:

  • All payers, self-pay, or no insurance
  • Ages 18 and above
  • All patients who had at least one visit. The visit window begins on January 1 of the Performance Year and ends whenever the practice site submits their roster.
    • If the patient had any visit in the window, in-person or telehealth, they are eligible.

Exclude as ineligible:

  • patients who are deceased, who reside in nursing homes/skilled nursing facilities, and patients whose addresses are outside the US.

People who live in residential care/assisted living facilities are eligible.

More details about the specifications for inclusion in the patient rosters/sample can be found in the Patient Roster Instructions and Frequently Asked Questions, on PCF Connect and in the PCF Portal. Practices may also refer to Chapter 4 of the Vendor Quality Assurance Guidelines, posted on the PCF PECS website.

How many patients will you sample from my practice? How do you decide how many to sample? Is there a minimum response rate?

Each year, CMS draws a random sample of rostered patients. The sample is designed to be representative of all rostered patients, and large enough to yield sufficient completed surveys to achieve an acceptable level of reliability (i.e., ability to find statistically significant differences between practices). CAHPS surveys and surveys that form the basis for payment determinations have widely accepted the coefficient of 0.70 as the threshold for interclass (i.e., between-practice) reliability. The PCF PECS follows recommended guidelines to determine the number of surveys needed to meet or exceed reliability of 0.70, based on practice size. There is no required minimum response rate for Performance-based Adjustment (PBA) scoring, but the survey vendor does send the survey to a large number of patients so that even if the response rate is low each practice can be expected to meet a minimum number of responses. The minimum number of responses is set to satisfy criteria for adequate measure reliability.

These targets) are high enough to yield a representative sample and achieve an 0.70 level of interclass reliability (i.e., the ability to find statistically significant differences between practices) on the survey domains. PCF, similar to CAHPS surveys and other surveys that form the basis for payment determinations, have widely accepted the coefficient of 0.70 as the threshold for interclass reliability. PCF, like most surveys which are used for making payment determinations, always bases scores on the responding patients. Practices' results are then risk-adjusted to remove any patient-level factors outside of the control of practices (for example patient health status, education or age) which may affect scores.

Survey Measures and Reporting

Which official CAHPS survey needs to be fielded for Primary Care First?

The PCF PECS is based on a combination of questions from the CG-CAHPS v.3.0 and CAHPS Patient-Centered Medical Home Item Set v. 3.0. A copy of the survey is posted on the PCF PECS web portal for vendors and practice sites and can be found here.

What kind of questions are asked in the PCF PECS?

The questions in the survey ask about health care experiences. For example, how hard or easy it is to get appointments, and if the patient's health care team listens and explains things in a way that is easy to understand. The survey is posted here on the PECS website.

Can practices add their own questions to the PCF PECS?

Yes, practices can add practice-specific questions as long as they abide by the requirements in the Quality Assurance Guidelines Section 5.5.6.

What if my practice's survey has a low response rate?

PCF PECS protocols are specifically designed to meet target response rates and yield the required number of completed surveys. If a practice does not meet the reliability threshold, CMS will use the responses that were received, and the scores will be calculated based on those responses.

Does CMS publicly report the results of PCF PECS anywhere?

The results of the PCF PECS are not publicly reported. Practice sites receive individual reports with summary data in late spring.

How will practices receive the results of the PCF PECS?

CMS prepares personalized, easy to understand score reports for each practice site​. The report reflects all Complete and Partially Complete surveys for that practice site.

FAQS FOR VENDORS

Participation

How does a vendor apply to become a PCF PECS approved vendor?

For the PY21 PCF PECS, CMS sent an invitation via email to vendors that are currently approved by CMS to conduct CAHPS surveys using mail and telephone modes. Vendors interested in applying for future years of the PCF model should be approved by CMS for the administration of CAHPS surveys using the above-mentioned modes.

Will CMS be approving additional vendors in future years?

Each January of the model, CMS will invite applications from vendors who are approved to conduct mail and phone CAHPS surveys for CMS. These vendors will be required to meet all of the minimum business requirements, complete the training, and submit an approved QAP to become fully approved. Once fully approved, vendors do not need to re-apply.

What are the requirements to become a survey vendor?

Invited survey vendors must complete an application to become conditionally approved. Conditionally approved vendors must 1) participate in the Introduction to the PCF PECS webinar training session; 2) successfully complete the training certification; and 3) complete and submit a Quality Assurance Plan.

When will the approved PCF PECS vendor list be released?

The PCF PECS Vendor Solicitation occurs in January of each Performance Year. The updated vendor list is published in May.

Who can vendors contact if they have questions about the PCF PECS?

Please contact the PCF PECS Team via e-mail at pcfpecs@rti.org or call 1-833-997-2715.

Can vendors advertise their conditional approval?

While CMS is not normally involved in the business side of survey vendor activities, we want to ensure practices are given accurate information. CMS will publish an official list of fully approved vendors no later than the end of May, each performance year. We request that any announcements made before this date specify that you are currently conditionally approved.

Is vendor training required annually?

After the survey vendor's (or Key-subcontractor's) first year of participation in PCF PECS, survey vendors will need to attend a PCF PECS Update Training Webinar training session. Attending the full Introduction to the PCF PECS Webinar training session is not required unless the survey vendor has a new staff person serving as their Survey Administrator who has not previously attended Introduction to the PCF PECS Webinar training.

Is a Quality Assurance Plan (QAP) required annually?

Yes, in subsequent performance years, vendors must submit QAPs annually to maintain their Full Approval status. When submitting a QAP after the first year, vendors should highlight any changes to their QAP from the prior submission. Vendors are also required to update/resubmit their QAP when there are major changes/updates to vendor staff or processes (regardless of the annual deadline).

Can vendors use existing BAAs with practices?

Yes, if they are current and accurate.

Is there a specific BAA form that must be used?

No. More information about Business Associates can be found here. An example BAA can be downloaded from here.

Survey Administration

Which official CAHPS survey needs to be fielded for Primary Care First?

The PCF PECS is based on a combination of questions from the CG-CAHPS v.3.0 and CAHPS Patient-Centered Medical Home Item Set v. 3.0. A copy of the survey is posted on the PCF PECS web portal for vendors and practices and can be found here.

When will data collection for the PCF PECS occur?

Data collection occurs in the fall of each performance year.

What are the data collection modes for the PCF PECS?

The PCF PECS is an annual survey conducted once per year. It is a single phase of data collection. Sampled patients will receive up to 2 mail surveys and 6 telephone calls over the 12-week data collection period.

Where can I find the survey materials for the PCF PECS?

The survey materials for the PCF PECS are posted here.

Where can I find the training materials for the PCF PECS?

The agenda and slides for the PCF PECS vendor webinar training are posted here.

Who will draw the sample?

CMS will draw the sample.

What languages are allowed for the PCF PECS administration?

All practice sites and vendors are required to offer survey administration in English and Spanish. CMS will provide all Spanish translations.

Are supplemental questions allowed for the PCF PECS administration?

Yes, practices can add practice-specific questions as long as they abide by the requirements in the Quality Assurance Guidelines Section 5.5.6.

Are survey vendors allowed to conduct some analysis and reporting for their client?

There are 7 guidelines found in the Quality Assurance Guidelines Section 8.4: (1) All reports provided to PCF PECS practice sites must include a disclaimer statement that the vendor results are not official CMS results and are for internal quality improvement purposes only. (2) Survey vendors may provide PCF practice sites with survey data or information from their practice as long as the survey vendor suppresses any display of data that includes cell sizes with fewer than 11 observations. (3) Survey vendors must have CMS approval to append data from the sample file to the survey data. (4) Survey vendors are not permitted to provide practices with patient identifying information. (5) Respondent names cannot be shared with practices, even if the respondent wishes to do so. (6) Added practice-specific questions may collect open ended comments or service information that could identify the patient. Reponses may have identifying data. You cannot share this with practices. (7) Survey vendors should contact the PCF PECS Team for additional guidance if they are not clear as to whether certain types of survey response data can be shared with a PCF practice site.