CMS Pub. 100-22, ch. 3, § 40

Required Quality Data

(Rev. 52, Issued: 12-18-15, Effective: 01-01-2016, Implementation: 04-01-16)

Section 3004 of the Affordable Care Act directs the Secretary to establish quality reporting requirements

for Hospice Agencies. In fiscal year 2014 and each subsequent year, if a hospice agency does not submit

required quality data, their payment rates for the year are reduced by 2 percentage points. CMS considers

the following data as meeting the reporting requirement:

• HIS data submitted by hospices for all patient admissions beginning on or after January 1 through

December 31, and

• Hospice CAHPS® Survey monthly data collection and submission from January 1 through

December 31.

NOTE: Reporting requirements consider data reporting by hospices beginning January 1, 2015 through

December 31, 2015 for fiscal year 2017 and after.

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 are reduced by 2 percentage points for that fiscal year. Application of the

2percentage point 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 FY involved.

Every year, CMS will provide Medicare contractors with a Technical Direction Letter (TDL) which

provides a list of hospice agencies that have not submitted the required HIS and/or hospice CAHPS survey

data during the established timeframes. Contractors must update the quality indicator in the Provider

Outpatient Specific File for each identified, hospice agency subject to the payment reduction. 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 and Hospice CAHPS® survey

data submitted by hospices to CMS for reporting periods beginning on or after January 1, through

December 31 as meeting the reporting requirements for that year.

In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79, FR 50487), CMS finalized

that hospices that receive notification of certification on or after November 1 of the preceding year

involved are excluded from any payment penalty for quality reporting purposes for the following FY. This

requirement was codified at §418.312.

Each spring, Medicare contractors with hospice workloads will receive a technical direction letter (TDL),

which provides a list of hospices that have not submitted the required hospice quality reporting data during

the established timeframes. The contractor shall notify the hospice that they have been identified as not

complying with the requirements of submitting quality data and are scheduled to have Medicare payments

to their agency reduced by 2 percentage points. Medicare contractors shall include the model language at

the end of this section in their initial notification letter to the hospices. The notification letter shall inform

the hospice whether they were identified as not being in compliance with the HIS data requirement, the

Hospice CAHPS survey data requirement or both. The notification letter shall also inform the hospice

regarding the process to dispute their payment reduction if they disagree with the determination. The

reconsideration process shall be outlined within the initial notification letter. Contractors shall send the

notification letters no later than 10 business days from the receipt of the TDL.

Immediately after the notification letters are issued, Medicare contractors shall submit to the CMS contacts

noted in the TDL a list of agencies who received a letter. Medicare contractors shall notify hospice

agencies who wish to dispute their payment reduction of the procedure to request a reconsideration. There

is a 30 day period from the date of the notification letter to submit a letter requesting reconsideration and

documentation to support a finding of compliance.

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. If clear evidence to support a

finding of compliance is not present, the 2-percentage point reduction will be upheld. If clear evidence of

compliance is present, the reduction will be reversed.

After the reconsideration process has occurred and prior to October 1 of each FY, CMS will provide the

Medicare contractors with a final list of hospices that failed to comply with the data submission

requirements. The Medicare contractors will then be responsible for notifying each hospice that failed to

comply with the quality data submission requirements that it will receive a 2 percentage point reduction in

payment. The Medicare contractors will also update the hospice provider file based on the appropriate

scenarios listed below. Medicare contractors shall include the model language at the end of this section in

the dispute notification letter to the hospices. Contractors shall send this second letter only to hospices that

requested a reconsideration. Additionally, the Medicare contractors shall include information regarding the

hospices right to further appeal the 2-percentage point reduction via the Provider Reimbursement Review

board (PRRB) appeals process. Contractors shall send the notification letters no later than 10 business

days from the receipt of the TDL.

If the hospice does not dispute their reduction, the Medicare contractor shall update their provider file for

the hospice. The contractor shall set an indicator in the provider file that triggers Medicare systems to

calculate the 2-percentage point reduction on all claims for the upcoming year. If the CMS determination

upholds the 2-percentage point reduction, the contractor shall update their provider file in this fashion also.

If the CMS determination reverses the 2-percentage point reduction, the contractor shall not update their

provider file for the hospice and shall notify the hospice that they will receive their full Hospice PPS

payment update for the upcoming year.

Model language for initial notification letters:

“This letter is to officially notify you that (Facility Name, CMS Certification Number 000000) is subject

to a reduction in payment for not meeting the Affordable Care Act (ACA) of 2010 requirement for

hospices to submit quality data. Therefore, Medicare payments to your agency will be reduced by 2

percentage points for [insert upcoming year]; unless you can provide evidence that, this determination is in

error. Currently, the quality data reporting requirement consists of timely submission of Hospice Item Set

(HIS) data and timely submission of Hospice Consumer Assessment of Healthcare Providers and Systems

(CAHPS®) Survey data. CMS review of HIS and Hospice CAHPS® Survey submissions for this period

found that your agency is noncompliant for the reporting requirements for [insert whether the hospice was

non-compliant with HIS, Hospice CAHPS®, or both].

If you believe you have been in compliance with the quality data reporting requirement and have been

identified for this payment reduction in error, you must submit an email requesting reconsideration and

provide documentation demonstrating your compliance. You have the right to request a reconsideration of

this decision. If you choose to request a reconsideration of this decision, you must submit the request no

later than 30 days following the receipt of this letter.

The request must include the following information:

• The Hospice CMS Certification Number (CCN),

• The Hospice business name,

• The Hospice business address,

• The Administrator contact information, including name, email address, telephone number, and

physical mailing address; or,

• The hospice may provide contact information for an Administrator-designated representative, to

include name, email address, telephone number, and physical mailing address; and,

• The reason(s) for requesting reconsideration.

The request for reconsideration must be accompanied by supporting documentation demonstrating

compliance. CMS will be unable to review any request that fails to provide the necessary documentation

along with the request for reconsideration. Supporting documentation may include any or all of the

following:

• Email communications,

• Evidence of HIS transmissions during the reporting period (e.g. an HIS Final Validation Report

from the CASPER system showing a timely submission date);

• For HIS reporting, proof of previous exemption/extension approval for the prescribed reporting

period.

• For hospices that have served fewer than 50 survey-eligible decedents/caregivers during the

reporting period, evidence that the hospice filed the Participation Exemption Request Form by

the deadline date and received approval from CMS.

• Notification of the CCN activation letter to prove that the CCN was not activated by November

1st.

• Evidence that the hospice continuously collected data and submitted data to the CAHPS®

Hospice Survey Data Warehouse during the required timeframe.

Documentation that does not support a finding of compliance is as follows:

• Evidence or admission of error on the part of hospice staff, even if the involved staff member

are no longer employed by the hospice and/or a corrective action plan has been or will be put in

place after the end of the reporting year;

• Evidence or assertion that failure to comply was the fault of a vendor or contractor that was

hired by the hospice to perform reporting functions;

• Evidence of delays establishing electronic data interchange connectivity between the hospice

and the Medicare claims processing contractor for the purpose of billing, since hospice quality

reporting data is not dependent on billing, and;

• In cases where the ownership of the hospice changed during the reporting year, but the CCN of

the hospice did not change evidence that failure to comply was the fault of the previous owner.

Your letter and documentation must be submitted via email to CMS for reconsideration, using the

following email address: HospiceQRPReconsiderations@cms.hhs.gov.

When preparing your request, be careful to ensure the following:

• Documents provided are relevant to the reason for your payment reduction (i.e. do not send HIS

documentation in response to a Hospice CAHPS® related reduction);

• No protected health information (PHI) is included in the documents;

• All documents pertain to the same, current reporting year;

• Each request provides documents regarding a single hospice (do not combine requests or attach a

list of hospice provider numbers to a request);

• If requesting a Hospice CAHPS® reconsideration regarding a participation exemption, provider

specific information detailing why your hospice had no eligible patients.

In its review of the hospice documentation, CMS will determine whether evidence to support a finding of

noncompliance has been provided by the hospice. The determination will be made based solely on the

documentation provided. CMS will not contact the hospice to request additional information or to clarify

incomplete or inconclusive information. For further questions related to the reconsideration process, please

refer to the following CMS hospice website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Reconsideration-Requests.html.”

A hospice must submit a request for reconsideration and receive a decision on that request before they can

file an appeal with the Provider Reimbursement Review Board (PRRB).”

The Medicare contractor shall update (or not update) the hospice provider file based on the appropriate

scenario listed below:

Upheld

• If the hospice was notified that it was potentially subject to the 2-percentage point reduction, and did not

request a reconsideration, then the Medicare contractor shall set a quality reporting indicator in the

provider file that triggers Medicare systems to calculate the 2 percentage point reduction on all of the

hospice’s claims for the upcoming fiscal year.

• If the hospice was notified that it was potentially subject to the 2 percentage point reduction, and

requested a reconsideration, but on reconsideration CMS upheld the decision to apply the 2 percentage

point reduction, then the Medicare contractor shall set a quality reporting indicator in the provider file that

triggers Medicare systems to calculate the 2 percentage point reduction on all of the hospice’s claims for

the upcoming fiscal year.

Reversed

• If the hospice was notified that it was potentially subject to the 2 percentage point reduction, and

requested a reconsideration, and on reconsideration CMS determined that the hospice should not be subject

to the 2 percentage point reduction (i.e., reversed its decision), then the Medicare contractor shall not

update the quality reporting indicator in the hospice’s provider file and shall notify the hospice that they

will receive their full hospice PPS payment update for the upcoming fiscal year.

• If the hospice submitted the necessary Hospice Quality Reporting data and was never notified that it

might potentially be subject to the 2 percentage point reduction, then the Medicare contractor shall take no

action regarding the quality reporting indicator in the hospice’s provider file.

Model language for dispute notification letters:

Upheld:

“Thank you for requesting a reconsideration of the determination made by the Centers for Medicare &

Medicaid Services (CMS) regarding reduction to this hospice’s annual update for failure to meet the

requirements of the Hospice Quality Reporting Program (HQRP).

CMS reviewed the reconsideration request of this hospice and is upholding the decision to reduce the

annual payment update for Medicare payments for Fiscal Year (FY) (insert upcoming year). Our records

indicate that this hospice did not provide evidence that it submitted required quality data during the

required timeframes. Therefore, for services provided by this hospice between October 1, (insert

upcoming year) and September 30, (insert upcoming year), the annual payment update for Medicare

payments for FY (insert upcoming year) will be reduced by two (2) percentage points.

If your agency wishes to further appeal this determination, the appeals process set forth in 42 CFR Part

405, Subpart R (a Provider Reimbursement Review Board (PRRB) appeal) applies. CMS appreciates the

opportunity to respond to the reconsideration request for the HQRP. For additional concerns related to the

reconsideration process, questions may be submitted to the following CMS email address:

HospiceQRPReconsiderations@cms.hhs.gov.”

Reversed:

“Thank you for requesting a reconsideration of the determination made by the Centers for Medicare &

Medicaid Services (CMS) regarding reduction to this hospice’s annual update for failure to meet the

requirements of the Hospice Quality Reporting Program (HQRP).

CMS reviewed the reconsideration request and determined that this hospice satisfactorily met the quality

data requirements for the FY (insert upcoming year) payment determination. Therefore, the two (2)

percentage point reduction to the FY (insert upcoming year) market basket update for failure to comply

with quality reporting requirements will not be applied.

CMS appreciates the opportunity to respond to this reconsideration request for the HQRP. For additional

concerns related to the reconsideration process, questions may be submitted to the following CMS email

address: HospiceQRPReconsiderations@cms.hhs.gov.”