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Reconsideration & Disaster Waiver Requests

06/27/2014

As previously announced by the Centers for Medicare & Medicaid Services (CMS) and implemented for  Fiscal Year (FY) 2014, the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) will once again reduce the annual increase factor by two (2) percentage points for FY 2015 if it is determined that a facility has been non-compliant with quality measure reporting requirements.  CMS will notify IRFs that are found to be non-compliant via certified United States Postal Service (USPS) letter. IRFs may request a reconsideration of a non-compliance determination through the CMS reconsideration request process described below. 

CMS will also provide all IRFs an opportunity to request a waiver from the program’s reporting requirements in the event the facility is/was unable to submit quality data due to extraordinary circumstances beyond their control. The IRF must submit a request for a waiver through the disaster waiver process (also found in this notice), within thirty (30) days of the date of the disaster or extraordinary circumstance.

Reconsideration Request Process

For payment determination FY 2015, IRFs were required to collect the following quality measures from January 1, 2013 through December 31, 2013, and submit the data according to the requirements outlined in the CY 2013 Hospital OPPS/ASC Final Rule:

  • NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) via the CDC National Healthcare Safety Network (NHSN)
  • Application of Percent of Residents or Patients 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, 2014. As previously mentioned above, IRFs found to be non-compliant with the quality reporting requirements will receive a letter of non-compliance along with instructions for requesting reconsideration of this decision.  Facilities identified for this payment reduction that disagree with this decision, may submit a request for reconsideration to CMS within thirty (30) days from the date of the non-compliance notification letter.  CMS will not accept any requests that are submitted after the thirty (30) day deadline.

Create a Reconsideration Request

Reconsideration forms are not available to IRFs.  Instead facilities are 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, e-mail address, telephone number and physical mailing address
  • Or, an IRF may provide contact information for a CEO-designated representative, including name, job title, e-mail 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 any or all of the following:

  • Proof of Submission;
  • E-mail communications;
  • Data submission reports from the Quality Improvement Evaluation System (QIES);
  • Data submission reports from the NHSN;
  • Proof of previous waiver approval;
  • Notification of the CCN activation letter to prove that the CCN was not activated by the end of the reporting quarter; or
  • Other documentation that may support the rationale for seeking reconsideration. 

Please ensure that no protected health information (PHI) is included in the documentation being submitted for review.

For Additional Information about How to See What your Facility Submitted

Additional information on how to review the data you submitted to CMS directly or via the CDC’s NHSN, please refer to the “Reviewing Your Reports IRF” document in the Download area below.

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 e-mail address: IRFQRPReconsiderations@cms.hhs.gov.  CMS will only consider requests for reconsideration once a provider has been found to be non-compliant, not before.  The 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 2015 payment determination:

  • June 23, 2014 – CMS issues notices of non-compliance to IRFs that failed to meet quality reporting requirements.
  • June 24– July 25, 2014 – Reconsideration requests are due to CMS 30 days from the date of the notification of non-compliance.
  • July – August 2014 – CMS provides an e-mail acknowledgement within 5 business days upon receipt of reconsideration request.
  • September 2014 – CMS notifies IRFs of the Agency’s decision on the reconsideration requests.

Filing an Appeal

IRFs that are dissatisfied with the result of the IRF QRP reconsideration, may file a claim under 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board [PRRB] appeal). Details are available at PRRB Review Instructions.

Disaster Waiver Process

All IRFs wishing to submit a request for a disaster waiver must submit the request within thirty (30) days of the date of the extraordinary circumstance. CMS may grant a waiver to the facility for the IRF quality reporting program for one or more quarters. CMS may also grant waivers to IRFs that have not requested a disaster waiver when it is determined that an extraordinary circumstance, such as an act of nature, affects an entire region or locale. CMS will communicate to facilities through routine channels if such determination is made.

IRFs may request a disaster waiver by using the following process: 

  • Compose a letter to CMS with the information describing the extraordinary circumstance and the  contact information for the IRF, including the facility’s CCN;
  • Submit the letter via e-mail with the subject line “Disaster Waiver Request” to the following address: IRFQRPReconsiderations@cms.hhs.gov.

CMS will provide a written acknowledgement upon receipt of the disaster waiver request. CMS will notify the CEO or CEO-designated contact with the decision.

For More Information:

For additional assistance, IRFs may submit questions related to the reconsideration request or IRF QRP disaster waiver requirements to: IRFQRPReconsiderations@cms.hhs.gov.