Reconsideration Overview

Process Regarding FY 2020 APU Decisions

Per Section 1886(b)(3)(B) of the Social Security Act, failure to meet requirements of the Hospital Inpatient Quality Reporting (IQR) Program will result in a reduction to a hospital’s Annual Payment Update (APU) by one-fourth of such applicable percentage increase. Also, hospitals that are subject to a payment reduction under the Hospital IQR Program are not eligible to participate in the Hospital Value-Based Purchasing (VBP) Program.

CMS is currently making APU decisions that will affect a hospital’s Medicare reimbursement between October 1, 2019 and September 30, 2020. This timeframe is known as Fiscal Year (FY) 2020. To make FY 2020 decisions, CMS reviews Calendar Year (CY) 2018 Hospital IQR Program data, unless otherwise noted.

CMS reviews all Hospital IQR Program requirements to make APU decisions; this review is done in two phases, called Phase 1 and Phase 2.

In Phase 1, CMS intends to notify hospitals that did not meet submission requirements in March 2019. In Phase 2, CMS intends to notify hospitals that did not meet the remaining program requirements in May 2019.

Specific requirements for each phase are detailed below.

Please be aware that CMS provides hospitals the opportunity to request a reconsideration of their APU reduction decisions.

Hospitals requesting Hospital IQR Program reconsideration from CMS must submit a Reconsideration Request Form (PDF) no later than 30 days from the date identified on the Hospital IQR Program Annual Payment Update (APU) Notification Letter provided to the hospital.

The request must, among other things:

  • Contain the CMS-identified reason that the hospital did not meet the APU requirements (as provided in the CMS APU Notification Letter to the hospital).
  • Identify the hospital’s specific reason(s) for believing the Hospital IQR Program requirements were met and why the hospital should receive the full FY 2020 Inpatient Prospective Payment System APU.
  • Include all documentation and evidence that supports the hospital's request for reconsideration at the time that it submits the request.

CMS will officially respond to the reconsideration request submitted by each hospital. CMS expects the process to take approximately 90 days from receipt of the reconsideration request.

For assistance in completing and/or submitting the Reconsideration Request, refer to the Reconsideration Quick Reference Guide (PDF).

Hospitals are encouraged to continue submitting all remaining Calendar Year (CY) 2018 data because some of those data are also used for calculating performance under the Hospital VBP and Hospital-Acquired Condition (HAC) Reduction Programs.

Validation reconsideration guidance

When the hospital's reconsideration request is related to validation (considered during the Phase 2 review), additional information may be needed, as described below.

Chart-Abstracted Validation
When the hospital's request is related to chart-abstracted validation, in addition to filing a Request for Reconsideration Form (PDF) as outlined above, the hospital must mail a completed Validation Review for Reconsideration Request Form (PDF), along with a paper copy of the entire medical record (as previously sent to the Clinical Data Abstraction Center [CDAC] Contractor) for the appealed element(s). The Validation Review for Reconsideration Request Form and paper copy of the entire medical record must be received for review by the Validation Support Contractor no later than 30 days from the date identified on the Hospital IQR Program APU Notification Letter provided to the hospital at:

Telligen
Attn: Validation Support Contractor
1776 West Lakes Parkway
West Des Moines, IA 50266

Electronic Clinical Quality Measure (eCQM) Validation
When the hospital’s reconsideration request is related to eCQM validation, complete and submit the Reconsideration Request Form by the deadline. No other form or submission of the medical record is required.

Phase 1 notifications

Listed below are the Hospital IQR Program requirements included in CMS' Phase 1 review:

  • Submission of aggregate initial patient population and sample size counts each quarter by the posted submission deadlines (First Quarter 2018–Third Quarter 2018).
  • Submission of data for each required clinical process measure, including Perinatal Care (PC-01), each quarter by the posted submission deadlines (First Quarter 2018–Third Quarter 2018).
  • Submission of Healthcare-Associated Infection (HAI) data to the National Healthcare Safety Network (NHSN) each quarter by the posted submission deadlines (First Quarter 2018–Third Quarter 2018).
  • Submission of Influenza Vaccination Coverage Among Healthcare Personnel (HCP) data to NHSN by the posted submission deadline for the 2017–2018 Influenza Season (Fourth Quarter 2017–First Quarter 2018).

Phase 2 notifications

Listed below are the Hospital IQR Program requirements included in CMS’s Phase 2 review.

  • Maintenance of an active QualityNet Security Administrator, regardless of whether the hospital submits data directly or uses a vendor.
  • Completion of a Notice of Participation (for newly reporting hospitals).
  • Submission of aggregate initial patient population and sample size counts each quarter by the posted submission deadlines (Fourth Quarter 2018).
  • Submission of data for each required clinical process measure, including Perinatal Care (PC-01), each quarter by the posted submission deadlines (Fourth Quarter 2018).
  • Submission of data for at least four electronic Clinical Quality Measures (eCQMs) for one self-selected quarter by the posted submission deadline (First Quarter 2018, Second Quarter 2018, Third Quarter 2018, or Fourth Quarter 2018).
  • Submission of Healthcare-Associated Infection (HAI) data to the National Healthcare Safety Network (NHSN) each quarter by the posted submission deadlines (Fourth Quarter 2018).
  • Submission of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey data each quarter by the posted submission deadlines (First Quarter 2018, Second Quarter 2018, Third Quarter 2018, and Fourth Quarter 2018).
  • Completion of the annual Data Accuracy and Completeness Acknowledgement (DACA) between April 1 and May 15, 2019.
  • Chart-Abstracted Data Validation: Achievement of a confidence interval validation score of 75 percent or greater (only for hospitals selected for this year’s chart-abstracted validation reviews).
  • eCQM Data Validation: Timely and complete submission of at least 75 percent of the records CMS requested (only for hospitals selected for eCQM validation reviews related to 2017 reporting).

Filing an appeal

When a hospital is dissatisfied with the result of CMS’ reconsideration decision, the hospital may file an appeal with the Provider Reimbursement Review Board (PRRB) under 42 CFR Part 405, Subpart R. Details are available at PRRB Review Instructions. An appeal can be filed with the PRRB only after the hospital has submitted a request for reconsideration and received an adverse decision on the request.

Reconsideration Resources

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