Before It’s Mandatory: Understanding OAS CAHPS 

Written by Christa Shephard

The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) will be mandatory for ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) starting January 2025. The OAS CAHPS survey gauges patient satisfaction in Medicare-certified HOPDs ASCs, focusing on areas such as communication, care quality, and facility conditions. 

The OAS CAHPS survey helps HOPDs and ASCs improve patient care and remain compliant with the Centers for Medicare & Medicaid Services’ (CMS’) regulations. The objective data collected from these surveys directly impacts public perception of outpatient healthcare facilities and empowers consumers to make informed choices between HOPDs and ASCs. Beginning in January 2025, ASCs that fail to participate could see a cut in their reimbursement rates. 

Voluntary participation in OAS CAHPS began with calendar year 2024, and mandatory participation begins with calendar year 2025. Participants may choose between mail-only, telephone-only, and mixed-mode (email with mail or telephone follow-up) administration with an annual target of 200 completed surveys for ASCs.  

The survey covers critical aspects of patient care: 

• Communication between patients and healthcare staff, ensuring patients feel heard and understood 

• Care and treatment regarding pain management and following up with patients 

• Facility cleanliness, which is an essential factor in patient satisfaction, especially in surgical settings 

ASC & Patient Eligibility 

An ASC is eligible to participate in the OAS CAHPS Survey if it meets all of the following criteria:  

• Performs procedures within the OAS CAHPS–eligible range (10004 and 69990) or G-codes G0104, G0105, G0121, or G0260  

• Is Medicare-certified, has a CCN, and has in effect an agreement with the Centers for Medicare & Medicaid Services (CMS) obtained in accordance with 42 CFR 416 subpart B (General Conditions and Requirements)  

• Bills under ASC Payment System when billing CMS  

• Is eligible to participate in the Ambulatory Surgical Center Quality Reporting (ASCQR) Program 

Patients are eligible to participate in the OAS CAHPS survey if they:  

• Had at least one eligible outpatient surgery/procedure during the sample month  

• Are least 18 years of age  

• Have a U.S. domestic mailing address  

• Are patients regardless of insurance or method of payment  

• Meet eligible CPT and G codes  

• Cannot be surveyed because of state regulations  

• Are not deceased  

• Do not reside in a nursing home  

• Were not discharged to hospice care or a psychiatric hospital following their surgery  

• Are not identified as prisoners  

• Are identified as “no publicity” 

Certain exemptions from participation will apply. ASCs that serve fewer than 60 OAS CAHPS survey–eligible patients in the year prior to the data collection year for the applicable payment determination qualify for a participation exemption. When an ASC qualifies for an exemption from the ASC Quality Reporting (ASCQR) program because it had fewer than 240 Medicare claims in the year prior to the data collection year, it also qualifies for an exemption from the OAS CAHPS survey for the same period. 

How to Prepare

ASCs should start aligning their operations with OAS CAHPS guidelines by improving patient communication strategies, optimizing pain management protocols, and maintaining high standards of cleanliness. No ASC can administer the survey itself; OAS CAHPS must be facilitated by a CMS-approved vendor. ASCs that have not begun the process of vetting, selecting, and engaging a CMS-approved vendor to administer the survey should begin as soon as possible.  

Once you’ve engaged a vendor, they should walk you through the steps to register for user credentials on the OAS CAHPS web portal and complete the CCN registration from your customized dashboard. Then, you will select and authorize your CMS-approved survey vendor to submit OAS CAHPS data on your behalf. Your vendor will confirm submission dates for monthly data files, complete a data collection and activities timeline per CMS guidelines based on your ASC’s mode of administration, and submit the data files to the OAS CAHPS data center via the survey website by the second Wednesday of January, April, July, and October. 

ASCs cannot:  

• Send or provide information to patients in advance.  

• Provide a copy of the OAS CAHPS survey questionnaire.  

• Include words or phrases verbatim from the survey.  

• Attempt to influence their patients’ CAHPS survey questions.  

• Offer participating or non-participating patients incentives of any kind for answers to the OAS survey.  

• Ask patients why they gave a certain response or rating.  

• Include any messages or materials promoting the HOPD or ASC survey. 

However, ASCs can include the following messaging: 

• The HOPD or ASC is participating in the survey to learn more about the quality of healthcare that patients receive.  

• Patients may be selected to participate in a survey about their experience at the facility.  

• Patients should anticipate an email or telephone call receiving the survey. 

Beat the Curve

It is essential for ASCs to begin the process of selecting and engaging a CMS-approved vendor to administer the OAS CAHPS survey. Educating staff on communication guidelines that align with these standards is key to ensuring compliance. By preparing now, ASCs can establish effective processes, enhance patient communication, and ensure a smooth transition when the requirements take effect. 

Stay informed and ensure your ASC is ready for the future by understanding the OAS CAHPS survey and its impact on your practice. Watch Progressive Surgical Solutions’ on-demand webinar to ensure your ASC has the knowledge and tools to stay ahead of the curve.