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Reconsideration & Disaster Waiver Requests

Beginning with Fiscal Year (FY) 2014, the Centers for Medicare & Medicaid Services (CMS) will reduce an inpatient rehabilitation facility’s annual payment update by 2 percentage points if that facility is found to be non-compliant with the reporting requirements of the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP). CMS will notify IRFs found to be non-compliant if it is determined that they have not met the reporting requirements for the IRF QRP. Those IRFs have the opportunity to request a reconsideration of this adverse decision through the Agency’s reconsideration request process described below. 

CMS will also provide IRFs an opportunity to request a waiver from the program’s reporting requirements in the event the IRF is unable to submit quality data due to extraordinary circumstances beyond their control. For the FY 2014 Payment Determination, the facility must submit a request for a waiver through the reconsideration process, addressed below.

Reconsideration Request Process

For payment determination FY 2014, IRFs are required to collect the following quality measures from October 1, 2012 through December 31, 2012, and submit the data according to the requirements outlined in the FY 2012 IRF Prospective Payment System (PPS) Final Rule:

  • Catheter-Associated Urinary Tract Infection (CAUTI) data (NQF #0138) to the CDC National Healthcare Safety Network (NHSN)
  • Percent of Residents with Pressure Ulcers That Are New or Worsened (short-stay) (NQF #0678) via the CMS Quality Improvement Evaluation System (QIES)

The deadline to submit the data for these measures was May 15, 2013. For IRFs found to be non-compliant with the quality reporting requirements, CMS will provide a letter of non-compliance to the IRF, along with instructions to request reconsideration.  IRFs that believe they have been identified for this payment reduction in error and believe they are in compliance with the quality data reporting requirements may submit a request for reconsideration to CMS within 30 days from the date of the notification of non-compliance.  CMS will not accept any requests that are submitted after the 30 day deadline.

Create a Reconsideration Request

Reconsideration forms will not be available to IRFs.  IRFs will be required to submit a reconsideration request to CMS via e-mail that must include the following information:

  • IRF CMS Certification Number (CCN)
  • IRF Business Name
  • IRF Business Address
  • CEO contact information, including: name, email address, telephone number and physical mailing address
  • Or, an IRF may provide contact information for a CEO-designated representative, including name, job title, email address, telephone number, and physical mailing address
  • CMS identified reason(s) for non-compliance from the non-compliance notification
  • Reason(s) for requesting reconsideration

The request for reconsideration MUST be accompanied by supporting documentation demonstrating compliance.  CMS will be unable to review any request that fails to provide the necessary documentation along with the request for reconsideration.  Supporting documentation may include copies of any data, email communications, data submission reports from the Quality Improvement Evaluation System (QIES), data submission reports from the NHSN, proof of previous waiver approval, or other documentation that may support the IRFs rationale for seeking reconsideration.  Please ensure no protected health information (PHI) is included in the documents.

  • To retrieve a copy of the data submitted for the CAUTI measure, providers may log into NHSN under their provider number and click the following links from the menu: Analysis > Output Options > Advanced > CMS Reports > CDC Defined Output to display a list of reports. From this list, providers may run the reports that are applicable to their facility type and the Healthcare-Associated Infection (HAI) data they wish to review. It is important to note that prior to generating a report, users should always first generate new datasets under the first link “Analysis” to ensure that all data recently entered is incorporated into the analyses.
  • To retrieve a copy of the data submitted for the Pressure Ulcer measure, providers may log into the Quality Improvement Evaluation System (QIES) under their provider number to run the IRF Assessment Print or the IRF Provider Final Validation report. The IRF Assessment Print allows providers to print the data submitted by assessment (i.e., one assessment at a time). The IRF Provider Final Validation report provides details about the status of the selected submission file.  IRF providers can review the necessary steps to access the above mentioned reports by doing the following:
    • Access the QTSO e-University page at https://www.qtso.com/webex/qiesclasses.php
    • Select the Other link located in the Recorded Training Sessions Categories box and the QTSO e-University login page will display.
    • Enter your first and last name and Email address in the Name and Email fields
    • Select the Go button and the Recorded Training Sessions page will display

Select the CASPER Reports for IRF Providers links from the Recorded Training Sessions box to view the recording.

 

Requests for Reconsideration due to a Disaster or Extraordinary Circumstances

IRFs that have been affected by an extraordinary situation such as a natural or man-made disaster or extraordinary circumstances that are beyond the control of the IRF, may request a waiver of the ACA 3004 quality reporting program requirements by filing a Request for Reconsideration,  using the same reconsideration process described above. The use of this process allows IRFs to request a retro-active waiver for the quality measure reporting requirements during the time that the facility was affected by the disaster. 

In the event that an IRF is notified that they were deficient in meeting the requirements of the Quality Reporting Program, and the IRF believes that the deficiency is due to a disaster, the IRF may indicate this in its request that CMS reconsider its decision.

It is important to note that  a request for reconsideration due to a deficiency  in the IRF reporting of the quality data as required in the Quality Reporting Program due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §412.614. 

Submit a Reconsideration Request

Reconsideration requests and supporting documentation must be submitted via e-mail with the subject line that contains the text: IRF ACA 3004 Reconsideration Request and your IRF CCN (e.g. IRF ACA 3004 Reconsideration Request, CCN = XXXXXX) to the following email address: IRFQRPReconsiderations@cms.hhs.gov.  CMS will only consider requests for reconsideration once a provider has been found to be non-compliant, not before.  Your facility must have received a CMS letter of non-compliance in order to apply for reconsideration.

Timeline for the Reconsideration Request Process

Below is the estimated reconsideration process timeline for FY 2014 payment determination:

  • June/July 2013 – CMS issues notices of non-compliance to IRFs that failed to meet quality reporting requirements.
  • July – August 2013 – Reconsideration requests are due to CMS 30 days from the date of the notification of non-compliance.
  • July – August 2013 – CMS provides an email acknowledgement within 5 business days upon receipt of reconsideration request.
  • September 201 3 – CMS notifies IRFs of the Agency’s decision on the reconsideration requests.

Filing an Appeal

If dissatisfied with CMS’s reconsideration decision rendered at the reconsideration level, an IRF can appeal the decision to  the Provider Reimbursement Review Board (PRRB) pursuant to the provisions under 42 CRF Part 405, Subpart R.  IRFs must submit a request for reconsideration and receive a decision on that request from CMS before they can file an appeal with the PRRB.  Details on how to submit an appeal can be found at PRRB Review Instructions.

For More Information:

Please check our IRF Reconsideration Manual, located under Downloads, prior to submitting questions to CMS. For additional assistance, IRFs may submit questions related to the reconsideration request or IRF QRP disaster waiver requirements to: IRFQRPReconsiderations@cms.hhs.gov.