Health Reform WK-EDGE PRRB upholds Medicare payment reduction for Las Vegas hospice
Tuesday, August 27, 2019

PRRB upholds Medicare payment reduction for Las Vegas hospice

By Dietrich Knauth

The hospice submitted ACA-mandated quality data on time, but in an improper Excel format.

The Provider Reimbursement Review Board denied a Las Vegas hospice’s appeal over a 2 percent reduction over its 2018 Medicare payments, finding that CMS was within its rights to reduce the payments after rejecting certain quality reporting data as improperly formatted (Southwest Medical Associates Hospice and Palliative Care v. National Government Services, Inc., PRRB Hearing, Dec. No. 2019-D30, Case No. 18-0934, June 26, 2019).

Southwest Medical Associates Hospice and Palliative Care was hit with a reduction in its "annual percentage update," or APU, which is meant to annually update the daily payment rate for hospice services based upon the inpatient market basket percentage increase. The Patient Protection and Affordable Care Act (ACA) made the annual increase partially contingent upon a hospice provider’s submission of certain quality data, allowing for a 2 percent reduction in the APU for hospices that failed to properly report the required quality data measures for a particular fiscal year.

For 2018, Southwest Medical Associates was required to submit reports for both the Hospice Item Set and the Hospice Consumer Assessment of Healthcare Providers and Systems, and CMS found that its Hospice Item Set data was improperly submitted. Although the data was submitted on time, it was transmitted in an Excel format that was ultimately rejected by CMS.

The hospice provider argued on appeal that its data submission was sufficient to avoid the two point penalty, and that the statute does not require a particular Excel format for the submission of the data. But the review board disagreed, finding that the statue requires hospices to submit the quality data" in a form and manner, and at a time, specified by the Secretary," giving the agency broad latitude to determine whether a report is acceptable or not.

"It is undisputed that SMA’s data submissions, while apparently timely filed, were not accepted by CMS because SMA did not submit its data in a form acceptable to the Secretary," the PRRB wrote.

The hospice also argued that it did not know the data was improperly formatted, and that it was being unfairly penalized for failing to perform additional validation checks after submitting its data. The review board disagreed, finding that the hospice should have known that additional verification could have revealed errors in its submission.

The user guide for the website used to upload Hospice Item Set data made several disclaimers explaining that successful upload of the data did not guarantee that it was accepted, according to the review board. The guide told hospices that errors in the uploaded data might only be identified after a 24-hour review period, and that hospices should print their upload confirmation messages in order to access final validation reports that might make them aware of errors in uploading the data.

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