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IRF Quality Public Reporting

Background:

Section 3004(b) of the Affordable Care Act established the IRF Quality Reporting Program (QRP). In addition, The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the reporting of standardized patient assessment data on quality, resource use, and other measures by Post-Acute Care (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.

IRF Compare

IRF Compare takes reported data and puts it into a format that can be used more readily by the public to get a snapshot of the quality of care each facility provides. For instance, this tool will help families compare some key quality metrics, such as pressure ulcers and readmissions, for over 1,100 IRFs across the nation.

Procedures for requesting CMS review of an IRF’s measure data: 

CMS encourages IRFs to review their data as provided in the Preview Reports.  If an IRF disagrees with performance data (numerator, denominator, or quality metric) contained within their Preview Report, they will have an opportunity to request review of that data by CMS.  In order to make such a request, IRF providers must adhere to the process outlined below:

  • Requests for CMS review of data may be submitted to CMS beginning on the day the provider preview reports are issued in IRF CASPER folders, and may be submitted through 11:59:59 p.m. PST on day 30 of the preview period.
  • CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
  • IRFs are required to submit their request to CMS via email with the subject line: “IRF Public Reporting Request for Review of Data” and include the IRF CMS Certification Number (CCN) (e.g., IRF Public Reporting Request for Review of Data, XXXXXX).  The request must be sent to the following email address: IRFPRquestions@cms.hhs.gov.  
  • The email request must include the following information:
  • IRF CMS Certification Number (CCN)
  • IRF Business Name
  • IRF Business Address
  • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
  • Information supporting the IRF’s belief that the data contained within the IRF’s Preview Report is erroneous (numerator, denominator, or quality measure calculation), including, but not limited to, the following: § Quality measures affected, and aspects of quality measures affected (numerator, denominator, quality metric)
  • IRFs will receive an email confirming receipt of their request.
  • CMS will review all requests and provide a response outlining the decision via email.  Please note that IRF-identified errors in data resulting from inaccurate data submissions that an IRF failed to correct will not be corrected.  CMS will not consider correcting quality measure calculations that providers find to be inaccurate due to missing data that was submitted beyond the applicable quarterly data submission deadline.  
  •  Data that CMS decides/agrees to correct will be corrected and displayed during the subsequent quarterly release of IRF quality data on IRF Compare.
  • Please note: The only method for submitting a request to CMS for review of your Preview Report data is via email. Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) in the request being submitted to CMS for review

Updates:

June 6, 2018

IRF Compare Quarterly Refresh Available

The June 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q3 2016 – Q2 2017, is now available. We invite you to visit IRF Compare to view the data. 

June 1, 2018

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 4 -2016 to Quarter 3 - 2017 data, prior to the September 2018 IRF Compare refresh, during which this data will be publicly displayed.

Providers have until July 1, 2018 to review their performance data.

Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

The updates include two additional assessment-based measures and four new claims-based measures.

New IRF Assessment-based measures:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)
  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)

New IRF Claims-based measures:

  • Medicare Spending per Beneficiary (MSPB)–PAC IRF QRP
  • Discharge to Community–PAC IRF QRP
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP
  • Potentially Preventable Within Stay Readmission Measure

The update also includes the removal of the All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Facilities measure.

For more information:

March 07, 2018 

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 3 -2016 to Quarter 2 - 2017 data, prior to the June 2018 IRF Compare refresh, during which this data will be publicly displayed.

Providers have until April 5, 2018 to review their performance data.

Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

For more information:

March 02, 2018

The March 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q2 2016 – Q1 2017, is now available. Visit IRF Compare to view the data. 

January 16, 2018

IRF Preview Reports: Flu Measure Error

CMS identified an error with the data displayed on the IRF Provider Preview Reports released on December 4, 2017, and related to the March 2018 refresh of the IRF Compare website.  The December 2017 Preview Reports incorrectly included data from a reporting period different than that identified in the reports’ headers.  This error affected the following quality measures: 

  1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680)
  2. Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431).

The IRF Provider Preview Report headers indicated that data for these measures represented patient assessment data for admissions and/or discharges that occurred between the dates of July 1, 2015 and June 30, 2016.  However, the data displayed on the reports was for the period July 1, 2016 through June 30, 2017.  Because of this discrepancy, CMS will be suppressing the display of this data for these two measures in the March 2018 IRF Compare refresh.  Providers that have questions about this suppression should submit their inquiries to the IRF Public Reporting helpdesk: IRFPRquestions@cms.hhs.gov.

January 04, 2018

New Guidance on How to Update IRF Demographic Data

The demographic data displayed on the Provider Preview Reports and on Inpatient Rehabilitation Facility Compare is generated from information stored in the Automated Survey Processing Environment (ASPEN) system.

If inaccurate demographic data is included on the Preview Report or on IRF Compare, facilities need to contact their Medicare Administrative Contractor (MAC) for assistance. When requesting updates to your demographic data, it is important to specify that you want your data within the ASPEN system updated, instead of referring to your data on the Compare site.

View the How to Update IRF Demographic Data 1-4-18 PDF in the downloads section.

Please note- updates to IRF Provider demographic information do not happen in real time and can take up to 6-months to appear on IRF Compare.

 

Please continue to check this webpage for updates.

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