Health Reform WK-EDGE Data submitted late does not protect provider from 2 percent penalty
Tuesday, January 30, 2018

Data submitted late does not protect provider from 2 percent penalty

By Susan Smith, J.D., M.A.

CMS properly imposed a 2 percent reduction for fiscal year (FY) 2017 on an acute care hospital for failing to timely report data related to influenza vaccination coverage, one of six required data under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP). The hospital’s IRF subunit submitted the missing data on July 27, 2016, after CMS had notified the hospital that it had failed to submit the data by the May 15, 2016, deadline. Citing to the statute, regulations, and relevant final rules, the Provider Reimbursement Review Board (PRRB) stated that the 2 percent penalty is mandated whenever a hospital fails to submit its IRF QRP data in the form and manner, and at a time specified by the Secretary. Although the hospital argued that because it eventually submitted the missing data, CMS is not authorized to penalize it, the PRRB concluded that it had no authority to consider factors outside those recognized by statute and regulations. (Mercy Hospital, Inc. dba Carolinas Healthcare System – Pineville v. Palmetto GBA c/o National Government Services, PRRB Hearing, Dec. No. 2018-D13, Case No. 17-1310, January 3, 2017).

Relevant laws, regulations, and final rules. The IRF QRP was added to the Social Security Act (SSA) by sec. 3004(b) and 3401(d) of the Patient Protection and Affordable Care Act (P.L. 111-148). Section 1886(j)(7)(C) of the SSA, requires IRFs to report on the quality of their services in the form, manner, and time specified by the Secretary. An IRF that fails to submit the required IRF QRP data is assessed a one-time 2 percent reduction in its annual update to the standard federal IRF prospective payment (see SSA 1886(j)(7)(A)(i); 42 C.F.R. sec. 412.624(c)(4)(i)).

In addition, the IRF prospective payment system (PPS) FY 2014 Final rule (78 FR 47860, August 6, 2013)), added the influenza vaccination coverage among healthcare personnel quality measure to the quality data requirements. CMS required providers to submit the data from October 1, or when the vaccine became available, through March 31, and imposed a May 15 deadline.

Companies: Mercy Hospital, Inc. dba Carolinas Healthcare System

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