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.

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.

Hospices see modest payment increase, new clinical doc reporting for FY 2018

Hospices serving Medicare beneficiaries would hospices would generally see a $180 million or 1 percent increase in their payments for fiscal year (FY) 2018 under a Proposed rule updating the hospice wage index, payment rates, and cap amounts. In an advance release of the Proposed rule, CMS also detailed new quality measure concepts under consideration for future years, solicited feedback on an enhanced data collection instrument, and described plans to publicly display quality measure data via the Hospice Compare website in 2017. CMS also seeks comments regarding the sources of clinical information for certifying terminal illness and would change the Hospice Quality Reporting Program (Hospice QRP), including adding new quality measures utilizing data collected in the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey. The Proposed rule is set to publish May 3, 2017.

Annual rates

Section 411(d) of the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10) (MACRA) amends section 1814(i) of the Social Security Act setting the market basket percentage for hospices in FY 2018 to 1 percent. This translates to about $180 million for hospices in the next fiscal year. In addition to the basket percentage increase, the cap amount for accounting years that end after September 30, 2016, and before October 1, 2025, must be updated by the hospice payment update percentage, rather than the Consumer Price Index (CPI). Therefore, the cap amount for FY 2018 will be $28,689.04 compared to the 2017 cap amount of $28,404.99.

Hospice CAHPS Survey

The Hospice CAHPS® Survey is a component of the Hospice Quality Reporting Program and is important for the hospice community because the results of the survey will allow for comparisons on a national basis. CMS noted that the data would help beneficiaries to select a hospice program, as well as encourage hospices to improve quality of care. Under the Proposed rule, two global CAHPS measures would be adopted. CMS expects to begin public reporting via a Hospice Compare Site in CY 2017 to help customers make informed choices.

Terminal illnesses

CMS’ expectation is that a referring physician/acute/post-acute care facility’s clinical documentation serves as the basis of the certification of terminal illness. As such, the agency is seeking comments on a clarifying proposal that would identify the source of clinical information, whether a referring physician or acute care facility, when certifying that life expectancy in a hospice situation is six months or less. CMS also wants to explore whether the use of clinical documentation from an in-person visit from the hospice medical director or the hospice physician member of the interdisciplinary group could support the certification of terminal illness and whether such documentation is needed to augment the clinical information from the referring physician/facility’s medical records.

Measures under consideration

CMS offered no new proposed measures, but did seek additional feedback on two claims-based measures under future consideration: (1) avoiding hospice care transitions and (2) accessing levels of hospice care. The agency noted it would be detailing the measures in future rulemaking.

$330M hospice payment rate increase in 2017

Hospices would see a proposed 2 percent increase in their payments for fiscal year (FY) 2017, amounting to a $330 million increase over FY 2016 numbers, along with changes to the hospice quality reporting program. In an advance release of a Proposed rule set to publish in the Federal Register on April 28, 2016, CMS shared its plan to update the hospice wage index, payment rates, and cap amount for FY 2017. The proposed 2 percent hospice payment update for FY 2017 is based on an estimated 2.8 percent inpatient hospital market basket update, reduced by a 0.5 percent productivity adjustment and by a 0.3 percent point adjustment set by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

The Proposed rule would also address the hospice quality reporting program, which was established by ACA sec. 3004(c), including the addition of new quality measures. CMS would solicit feedback on an enhanced data collection tool and a plan to publicly display quality measures and other hospice data beginning in the middle of 2017. The Proposed rule would update hospice monitoring data analysis and provides discussion about ongoing monitoring efforts. Starting in FY 2014, hospices that fail to meet quality reporting requirements receive a 2 percent reduction to their payments.

Public reporting of hospice information via a Health Compare website will be available some time in calendar year 2017.

Payment cap update

In the FY 2016 Hospice Wage Index and Payment Rate Update Final rule (see Hospice 2016 rate update will bring $160M payment increase, Health Law Daily, August 6, 2015), CMS implemented changes that updated the hospice payment update by percentage rather than using the consumer price index for urban consumers. As required by Soc. Sec. Act sec. 1814(i)(2)(B)(ii), the hospice cap amount for the 2017 cap year will be $28,377.17, which is equal to the 2016 cap amount ($27,820.75) updated by the FY 2017 hospice payment update percentage of 2.0 percent.

The 2017 cap year will start on October 1, 2016, and end on September 30, 2017, as the FY 2016 Final rule had set the alignment of the cap accounting year with the federal fiscal year beginning in 2017.

Quality measures and data collection

Two new quality measures are proposed for FY 2017. The first measure—Hospice Visits When Death is Imminent—would assess hospice staff visits to patient and caregivers in the last week of life. The second measure—Hospice and Palliative Care Composite Process Measure—would assess the percentage of hospice patients who received care consistent with the guidelines. The second measure would be based on measures from the seven currently submitted under the Hospice quality reporting program (QRP).

CMS would enhance the current hospice data collection tool to be more in line with other post-acute care settings. The data collection would be a comprehensive patient assessment tool, rather than the current chart abstraction tool. According to the agency, hospices could use the data as a foundation for valid and reliable information for patient assessment, care planning, and service delivery. The expectation is that there would be greater accuracy in quality reporting, reduction to provider burdens, assurance for hospices fulfilling conditions of participation, and higher quality patient care. CMS also believes that with the data collection tool, future payment determinations could be made.

Additional ACA impact

The Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®) Survey is a component of the Hospice QRP required under the ACA. The Proposed rule provides detailed description of the Hospice CAHPS® Survey, including the model of survey implementation, the survey respondents, eligibility criteria for the sample, and the languages in which the survey is offered, as well as participation requirements for FY 2019 and 2020. Public display of the survey results will not occur until CMS has collected at least four quarters of data. CMS expects public display of the data to occur during CY 2017 at the CAHPS® HOSPICE Survey website.