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From Health Law Daily, March 5, 2018

Hospital properly hit with payment reduction for failing to file quality data

By Jeffrey H. Brochin, J.D.

The Provider Reimbursement Review Board (PRRB) upheld a CMS decision that imposed a payment reduction to a hospital’s market update basket under the Hospital Inpatient Quality Reporting (IQR) program. The IQR program required the hospital to submit quality of care data in the form and manner, and at a time specified by CMS, and their failure to do so warranted the penalty of reduction in the hospital’s inpatient prospective payment system (IPPS) payments. Because of the penalty, the hospital was also excluded from participation in the value-based purchasing (VBP) program (Westchester General Hospital v. First Coast Service Options, PRRB Hearing, Dec. No. 2017-D18, Case No. 15-1879, February 12, 2018).

Background. On May 21, 2014, CMS notified Westchester General Hospital that it failed to meet IQR program requirements which would result in a one-fourth reduction in Westchester’s fiscal year (FY) 2015 market basket update payment. Specifically, CMS alleged that Westchester failed to timely report Healthcare Associated Infection (HAI) data for the fourth quarter of calendar year (CY) 2013 as required under the IQR program. Following Westchester’s request for reconsideration, CMS upheld its decision, and the present PRRB appeal ensued.

HAI and patient safety data. The IQR Program requires hospitals to submit various HAI data and patient safety data, including data regarding Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C. Diff) infections to the Centers for Disease Control and Prevention (CDC) through a CDC computer system called the National Healthcare Safety Network (NHSN).

Issue of timely submission. By letter dated May 21, 2014, CMS informed Westchester that it did notmeet IQR program requirements and that its FY 2015 market basket update would be reduced by one-quarter. Specifically, the letter stated that Westchester did not submit MRSA or C. Diff data to the NHSN for the fourth quarter 2013 by the posted submission deadline. Westchester, however, disputed the CMS claim contending that it timely submitted its MRSA and C. Diff data for the fourth quarter of calendar year 2013, and whether or not CMS ultimately received the data was a CMS or CDC issue, based on a technical shortcoming of the NHSN system. Westchester further noted that the NHSN system did not send any alerts or identify any outstanding action items which would have notified Westchester of missing data, and in fact the NHSN showed a message of "you have no action items." Westchester believed that its reliance on the NHSN’s alerts and outstanding action items was reasonable because they had proven reliable in the past.

The first indication that data was missing was when a representative from Florida’s Quality Improvement Organization (QIO) emailed Westchester on May 14, 2013 to inform the hospital that its data submission was incomplete. Again on May 21, 2014 the QIO representative sent an e-mail to Westchester stating there was a "non-submission of C. difficile and MRSA data for the 4th quarter 2013." When Westchester realized some of its summary data was missing it submitted the missing data on May 23, 2014, which was after the May 15, 2014 deadline. Westchester believed that its submission should have been deemed timely due to its reliance on the NHSN’s alerts.

Failure to file plan lead to alert problem. Westchester’s Medicare Contractor, First Coast Service Options, pointed out that Westchester did not submit a complete plan for the fourth quarter of 2013 for a certain monthly Medicare module until June 9, 2014 which was after the May 15, 2014 deadline, and that when a monthly reporting plan is not completed, information will not transmit to CMS. In addition, when a plan is missing, the NHSN system will not transmit any alerts notifying of specific measures that were not reported to CMS because the monthly plan is necessary in order for the NHSN system to know what specific measures it is monitoring. Without that information the system cannot generate alerts notifying the hospital of reporting errors.

No reliance on alerts. The PRRB found that the NHSN manual requires that each participating institution must enter a monthly plan to indicate the modules used, if any, and the events, locations and/or procedures monitored. Although the PRRB considered that Westchester may have in the past relied on the NHSN’s alerts to identify missing information, the PRRB found no evidence in the record indicating that alerts or outstanding action items were the means by which CMS informs hospitals of missing data. Based on the forgoing, the PRRB concluded that it was Westchester’s fault, and not the fault of the NHSN, that Westchester’s quality data was not submitted to CMS in the required form and manner by the May 15, 2014 deadline.

Accordingly, the payment reduction to Westchester’s market basket update for FY 2015 was deemed proper.

Cost reporting period ending September 30, 2015.

MainStory: TopStory PRRBDecisions IPPSNews CMSNews MedicareContractorNews PaymentNews QualityNews

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