CMS Releases Updated Hospice Quality Reporting Program Information
August 16, 2013 11:34 AM
On August 13, 2013 CMS posted Hospice Quality Reporting Program (HQRP) training materials and results from the analysis of the NQF #0209 data that was submitted by hospices to the HQRP webpage.
Training materials posted include:
HQRP General Information Fact Sheet
Fact Sheet FY2015 Reporting Cycle
User Guide for Data Collection FY2015 Reporting Cycle
Training Slides for Data Collection FY2015 Reporting Cycle
Results from the analysis of the NQF #0209 are based on measure data collected at three time points – the voluntary reporting period, the pilot test of the HIS (Hospice Item Set), and data submitted by hospices for mandatory reporting in 2013.
Findings indicate that there were significant discrepancies in data collection as well as in the crosswalk between hospice patient assessments and the data elements included in the HIS. Data analysis also revealed an unexpectedly high rate of patient exclusion from the measure. Exclusion was primarily related to a high number of patients unable to self-report, and patients not reporting pain on admission. CMS has indicated it will not include the current NQF #0209 measure in the HQRP beyond payment year 2015.
The HQRP currently operates on a cycle of data collection, data submission, and payment impact that spans three years. HQRP reporting cycles are referenced by the payment year they impact. For example, the current HQRP cycle, Payment Year 2015 Cycle will consist of data collection in 2013, data submission in 2014, impacting the Annual Payment Update (APU) for 2015.
The HQRP is currently a “pay for reporting” system meaning hospices are not penalized for the outcomes achieved on the quality measures. Hospices are penalized with a two percent reduction in their APU for the payment year for which a hospice does not report any data by the submission deadline. The two percent APU reduction is not cumulative meaning that it only impacts the payment year for which data was not submitted and not any payment years beyond that.
All hospices with a CCN (CMS Certification Number commonly known as provider number) as of March 3, 2014 must meet the April 1, 2014 submission and attestation deadline. If the hospice was certified but did not have an assigned CCN on March 3, 2014 the hospice is excluded for reporting. If a hospice starts anew after December 31, 2013 but has a CCN assigned by March 3, 2014 it must still meet the April 1 deadline. In this situation, it is important to reiterate that the HQRP is currently a pay for reporting system and the performance of the hospice on the measures is not a consideration in the APU reduction decision.
For payment year 2015 hospices will report on two measures – a structural measure and a pain measure (NQF #0209). Hospice providers will report to CMS via a web-based data entry and submission website. The data entry website will be available for data entry, attestation, and data submission January –April 1, 2014.
All submissions and attestations must be complete by 11:59 PM Eastern on April 1, 2014 in order to avoid the two percent APU reduction for FY2015.
Hospices will report data by CCN. Therefore, hospices with multiple locations under one CCN will aggregate their data for submission. Hospices must report on the measures directly to CMS via the web portal or utilize a vendor to report on their behalf. Vendors will not be able to do any batch reporting. The vendor will have to do the reporting for each hospice individually via the web portal. This may change for future reporting but CMS has not indicated anything further about this at this time.
NAHC will continue to monitor the HQRP webpage for any additional updates and specifically for the technical user guide posting. We will notify you of any information as it becomes available.