Burden on submitter of quality data to verify successful transmittal

When a provider is required to submit data to CMS by entering data into a system that verifies the data and then transmits it to CMS, it is the provider’s duty to ensure that the data is actually transmitted to CMS. The Provider Reimbursement Review Board (PRRB) held that it is not enough to simply input information into the system when there are mechanisms in place to confirm that the data was successfully transmitted to CMS (Horizon Home Care & Hospice v. National Government Services, PRRB Hearing, Dec. No. 2018-D30, Case No. 16-0143, March 29, 2018).

Background

A hospice provider submitted admission and discharge data files to CMS via the Quality Improvement Evaluation System (QIES) as required under the Social Security Act (the Act). After submitting the information, the system provided a message indicating that the submission file was being processed for errors and a Final Validation Report would be available in the CASPER Reporting application once the data was transmitted to CMS. The hospice provider assumed that the submission was accepted and never accessed the CASPER Reporting application to obtain a copy of the Final Validation report.

The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) ties submission of certain mandatory quality data to a provider’s eligibility for the annual Medicare hospice benefit increase or market basket update. It also mandates that a hospice’s market basket update be reduced by 2 percent if it failed to report the required quality data. Per this mandate, the Medicare contractor notified the hospice provider that its Annual Payment Update was being reduced by 2 percent.

After checking the CASPER system, the hospice provider discovered that the final validation report indicated that the data contained a facility identifier error and was never transmitted to CMS. The hospice provider requested that CMS reconsider its decision. CMS upheld its payment reduction and the hospice provider appealed the reconsideration decision to the Board.

QRP rule

The hospice provider argues that the plain language of the Quality Reporting Program (QRP) Rule requires that a hospice provider submit the data to CMS but does not require that the CASPER system receive the data from QIES. The Medicare contractor argues that the rule clearly states that the quality “data must be submitted in a form and manner, and at a time, as specified by the Secretary.” The Medicare contractor further argues that it is the provider’s duty to submit the data accurately, completely and timely.

The QIES system notified the hospice provider that it should obtain a validation report from the CASPER system. The Hospice Item Set manual and submission user’s guide both warn that if fatal errors are found, the record will be rejected and a validation report should be run to ensure the data was successfully transmitted. In the 2014 Guidance Manual, CMS warns that the system will provide fatal error and/or warning messages on the Final Validation Report for submitted data that does not meet the requirements.

Decision

The PRRB held that the provider is not required to review and printout its final validation report, however it is in the provider’s best interest to run the validation reports to confirm that the data was input correctly and transmitted from QIES to CASPER. The hospice provider did not perform the recommended steps prior to the submission deadline to assure that the quality data it entered into QIES was error free and transferred to CASPER. Therefore, the hospice provider did not submit the quality data in the form and manner and at the time required by the Act.

Report shows management of CMS payment program shows vulnerabilities

While CMS has made some progress towards addressing problems with the Quality Payment Program (QPP), a new report shows vulnerabilities remain regarding technical assistance for clinicians and the potential for fraud and improper payments. The HHS Office of the Inspector General (OIG) report noted that if CMS fails to sufficiently address these issues, clinicians may struggle to success under the QPP or choose not to participate. The report also found that CMS needs to put systems in place to effectively prevent, detect, and address fraud and improper payments.

CMS is implementing core provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) as the QPP, a set of clinician payment reforms designed to put increased focus on the quality and value of care. The QPP is a significant shift in how Medicare calculates payment for clinicians and requires CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care.

Technical assistance

The report shows that if clinicians do not receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate. Clinician feedback collected by CMS demonstrates widespread basic awareness of the QPP, but also indicates uncertainty regarding details of participation such as who must report and how to submit data. CMS contractors have focused largely on general education initiatives, with fewer resources devoted to more customized, practice-specific technical assistance. CMS has established a Service Center to answer questions about the QPP by phone or email. Service Center data indicate that clinicians continue to have questions about both eligibility and scoring criteria, and that small practices, in particular, need information and assistance. Small practices and clinicians in rural or medically underserved areas, who may have fewer administrative resources and less experience with prior CMS quality programs, should be prioritized for assistance. The report stated, “Clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program.”

Fraud

The report also found that if CMS does not develop and implement a comprehensive QPP program integrity plan, the program will be at greater risk of fraud and improper payments. To ensure that the QPP succeeds, CMS must effectively prevent, detect, and address fraud and improper payments. QPP payment adjustments are intended to reward high-value, high-quality care. Safeguarding the validity of Merit-based Incentive Payment System (MIPS) data and the accuracy of QPP payment adjustments is critical to ensure that these payments are based on clinicians’ actual performance. Appropriate oversight is critical to prevent fraud and improper payment adjustments. CMS needs to clearly designate leadership responsibility for QPP program integrity. CMS also needs to develop a comprehensive program-integrity plan for the GPP to ensure the accuracy of MIPS data submitted by clinicians. CMS said that it “is currently in the early stages of developing an oversight plan to QPP data.”

CMS announces Hospice Compare website

CMS released the Hospice Compare website on August 17, 2107. The website allows consumers to make informed decisions about hospice providers based upon the quality of care they provide. Consumers can use the website to find providers in their area and compare them using quality of care metrics.

Reporting

 Hospices are required to report to CMS on several quality measures under Section 1814(i)(5) of the Social Security Act (SSA). The Hospice Quality Reporting Program (HQRP) requires hospice providers to submit data from the Hospice Item Set (HIS) and Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®). The Hospice Compare website compiles data so that consumers can evaluate things like the percentage of patients that were screened for pain or difficulty breathing and whether patients’ preferences were satisfied. The website compiles data from 3,786 hospice providers.

Measures

The Hospice measure set displayed on the website currently includes the following National Quality Forum (NQF) measures from the HIS:

  • Hospice and Palliative Care- Treatment Preferences – NQF #1641
  • Hospice and Palliative Care- Beliefs/Values Addressed- NQF #1647
  • Hospice and Palliative Care- Pain Screening- NQF #1634
  • Hospice and Palliative Care- Pain Assessment- NQF #1637
  • Hospice and Palliative Care- Dyspnea Screening- NQF #1639
  • Hospice and Palliative Care- Dyspnea Treatment- NQF #1638
  • Hospice and Palliative Care- Patients treated with opioids who are given a bowel regimen- NQF #1617

The website will be updated to include the CAHPS data in winter 2018.

AMA provides resources to help physicians with MIPS reporting

As part of its effort to improve Medicare Payment Reform, the American Medical Association (AMA) is providing tools for physicians to better understand and meet the reporting requirements under the new Quality Payment Program from CMS. The AMA has created a “One Patient, One Measure, No Penalty” campaign to help physicians understand the reporting requirements and avoid the 4 percent penalty for not reporting under the Merit-Based Incentive Payment System (MIPS) track. Along with this campaign, the AMA has created an interactive MIPS Action Plan that provides deadlines and a step-by-step plan of how to meet the reporting requirement deadlines.

As part of the “One Patient, One Measure, No Penalty” campaign, the AMA has provided a short video that demonstrates how to fill out CMS forms to accurately report a quality measure on a patient encounter. A step-by-step guide is also provided as a supplement to the video, along with a sample form to review. There are also links to other tools, such as the CMS Quality Measure Search tool, so that all of the resources are available in one easy-to-find location.

The MIPS Action Plan is a ten-step plan that begins with a determination of whether MIPS applies to the physician. The AMA provides a detailed breakdown of some of the determining factors, such as whether a physician is considered a hospital-based physician, in a frequently asked questions supplemental resource. The MIPS Action Plan then proceeds to walk through the process of reporting, including deadlines to start reporting, and submitting 2017 MIPS data.