By Rebecca Mayo, J.D.
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.
Fiscal Period – 2016.
Companies: Horizon Home Care & Hospice, Inc.; National Government Services
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