CMS Releases Change Request Outlining Penalties for Hospice Agencies that Do Not Submit Required Quality Data
March 12, 2015 12:05 PM
The Centers for Medicare & Medicaid Services (CMS) on March 6, 2015, released change request (CR) 9091, which addresses payment to hospice agencies that do not submit required quality data and outlines the penalties for failure to report.
For fiscal year 2014, and each subsequent year, if a hospice agency does not submit required quality data, their payment rates for the year will be reduced by 2% for that fiscal year. Application of the 2% reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year. In addition, reporting-based reductions to the market basket increase factor will not be cumulative; they will only apply for the fiscal year involved.
For calendar year 2014, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after July 1, 2014, through December 31, 2014, as meeting the reporting requirements. For calendar year 2015 and subsequent years, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after January 1 through December 31 as meeting the reporting requirements for that year. Hospices that receive notification of Medicare certification on or after November 1 of the preceding year involved are excluded from any payment penalty for quality reporting purposes for the following fiscal year.
CMS updated Section 40, Chapter 3, of the Medicare Quality Reporting Incentive Programs Manual with the details of this process. Each spring CMS will send the list of hospices not participating to the appropriate Medicare Administrative Contractor (MAC). The MACs in turn will send a letter to each hospice notifying them about the 2% reduction to their payments and outlining the process the hospice needs to follow for reconsideration of the decision. CMS will then review all reconsideration requests received and provide a determination to the Medicare contractor typically within a period of 2 to 3 months. In its review of the hospice documentation, CMS will determine whether evidence to support a finding of compliance has been provided by the hospice. The determination will be made based solely on the documentation provided. No additional documentation will be requested. If clear evidence to support a finding of compliance is not present, the 2% reduction will be upheld. If clear evidence of compliance is present, the reduction will be reversed.
Both the reconsideration decision and the CMS notification to the MAC of the decision are to be completed prior to October 1 each year. Within 10 days after CMS notifies the MAC, the MAC will then notify the relevant hospice of the CMS decision of whether to grant or deny reconsideration. Hospices do have the right to further appeal the 2% reduction via the Provider Reimbursement Review Board (PRRB) appeals process.
For additional information, including a list of information that must be included in the request for reconsideration, see CR 9091; an accompanying Medlearn Matters Article (MM9091) has also been posted online.