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.

Compare websites for IRFs and LTCHs have launched

The quality of patient care that inpatient rehabilitation and long-term care facilities provide to patients can vary greatly from facility to facility. To allow patients, family members, and health care providers to get a snapshot of the quality of care each inpatient rehabilitation facility (IRF) and long-term care hospital (LTCH) facility provides, CMS has announced the launch of the IRF Compare and LTCH Compare websites.

It is hoped that the information on IRF and LTCH Compare will help patients make more informed decisions about where they get their health care and encourage these facilities to improve the quality of care they provide. IRF Compare currently contains data from approximately 87 percent of all IRFs and LTCH Compare contains data from approximately 97 percent of all LTCHs.

Basis for establishment

These Compare websites were created to fulfill the requirements of the LTCH Quality Reporting and the IRF Quality Reporting Programs, which were established by section 3004(a) and (b) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), respectively, and required the Secretary of HHS to establish procedures for making quality data submitted by IRFs and LTCHs available to the public.

Current quality measures

Currently, there are two quality measures that are being displayed on the IRF and LTCH Compare websites: (1) the percent of residents or patients with pressure ulcers that are new or worsened (short stay); and (2) the all-cause unplanned readmission percentage for 30 days post discharge.

IRF data for the percent of residents or patients with new or worsened pressure ulcers was collected and submitted to CMS via the IRF Patient Assessment Instrument. The national measure for new or worsened pressure ulcers in IRFs is 0.8 percent. Data for the all-cause unplanned readmission measure for 30 days post-discharge is based on Medicare fee-for-service claims submitted by IRFs and other hospital providers. The IRF national average for all-cause readmission 30 days post discharge is 13.06 percent.

LTCH data for the percent of residents or patients with new or worsened pressure ulcers was collected and submitted to CMS via the LTCH Continuity Assessment Record & Evaluation Data Set, which is an assessment-based data collection instrument created by CMS. The national measure for new or worsened pressure ulcers is 1.8 percent for LTCHs. Data for the all-cause unplanned readmission measure for 30 days post discharge from LTCHs is based on Medicare fee-for-service claims submitted by LTCH and other hospital providers. The national average for all-cause readmission 30 days post discharge is 24.61 percent for LTCHs.

Healthcare-acquired infections to be added soon

The Centers for Disease Control and Prevention (CDC) is currently making efforts to implement a new national baseline for healthcare-acquired infections (HAIs) that are reported to CMS via the CDC’s National Healthcare Safety Network (NHSN). As such, CMS will wait until spring 2017 to begin publishing HAI data on the IRF and LTCH Compare websites.

Review of data

CMS encourages IRFs and LTCHs to review their data as provided in their preview reports.If they disagree with performance data contained within their preview reports, they have an opportunity to request review of that data by CMS. The process for submitting a request is outlined on CMS’ IRF Quality Public Reporting and LTCH Quality Public Reporting webpages.

Spring 2017 data for IRFs are ready for review

The IRF QRP provider preview reports are now available for review and are scheduled for a spring 2017 posting. IRFs should review their performance data on each quality measure based on Quarter 2-2015 to Quarter 1-2016 data prior to its public display on IRF Compare in the spring of 2017.

IRFs have 30 days (from December 11, 2016 through January 10, 2017) to review their performance data. Corrections to the underlying data will not be permitted during this time; but IRFs may request CMS review of the data contained within their preview report, should they believe it to be inaccurate.