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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 formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each facility. This tool helps 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:
  1. IRF CMS Certification Number (CCN)
  2. IRF Business Name
  3. IRF Business Address
  4. CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
  5. 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. Also, 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:

September 11, 2019

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available.  The data contained within the Preview Reports is based on quality data submitted by IRFs between Quarter 2 – 2018 and Quarter 1 – 2019, and reflects what will be published on IRF Compare during the December 2019 refresh of the website. Providers have 30 days (9/11/19 to 10/11/19) to review their performance data. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate. 

As a reminder, data for the quality measure Percent of Residents or Patients that have New or Worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 – Quarter 2 2018. This data will continue to be publicly displayed until such time as the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the FY 2018 IRF PPS Final Rule. 

As of the December 2019 refresh, CMS will no longer publicly display the National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia outcome measure, as finalized in the FY 2019 IRF PPS Final Rule. This change is reflected in your preview reports. 

For more information:

June 10, 2019

IRF Provider Preview Reports- Now Available


Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. The data contained within the Preview Reports is based on quality data submitted by IRFs between Quarter 4 – 2017 and Quarter 3 – 2018 and reflects what will be published on IRF Compare during the September 2019 refresh of the website. Providers have until July 10, 2019 to review their performance data. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

Beginning with the September 2019 refresh, CMS will publicly display measure results on the IRF Compare website for the following two measures: the Potentially Preventable 30-Day Post-Discharge Readmissions and Potentially Preventable Within-Stay Readmissions measures adopted for the IRF Quality Reporting Program (QRP). We postponed publishing these measures in late 2018 to allow more testing to ensure they provide a reliable, accurate picture of provider performance on quality, in line with CMS’s Meaningful Measures Initiative to address high-priority areas for quality measurement with measures that will help improve patient outcomes while minimizing provider burden. We have since completed this additional testing and have refined the method for assigning providers to performance categories, in which their performance level is compared to the national rate. IRF performance data for these measures will be included for the first time on this preview report.

CMS is additionally previewing the Discharge to Community (DTC) measure for the first time, using updated methodology for assigning categorical ratings to each provider based on their performance on this measure (better than, same as, or worse than the national average).

For more information on:

• The IRF data referenced in the above messaging, we invite you to view the IRF Quality Public Reporting webpage, IRF Compare, and/or Preview Report Access Instructions
• Potentially Preventable Readmissions measures, we invite you to view our related Fact Sheet and Q & A documents on the IRF QRP Public Reporting webpage, under the Downloads section
• The newly updated methodology used to assign categorical ratings to providers with respect to their performance on the DTC measure, as referenced above, we invite you to view our related Fact Sheet and Q & A documents on the IRF QRP Public Reporting webpage, under the Downloads section

June 05, 2019

IRF Compare Quarterly Refresh

The June 2019 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including updated quality measure results based on data submitted to CMS between Quarter 3 2017 – Quarter 2 2018, is now available.

Please visit the IRF Compare website to view the updated quality data.

May 31, 2019

Update of the Discharge to Community Measure for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)

The IRF DTC measure was first displayed on the IRF Compare website in fall 2018 and will be refreshed in fall 2019. CMS has refined the statistical methodology for assigning providers to performance categories for public display to align with the Potentially Preventable Readmissions measures in the PAC QRPs and the Hospital-Wide Readmission measure in the Inpatient QRP. This refinement results in greater variation in provider performance categories, allowing better discernment of providers that underperform or overperform considerably compared with the national rate. The refinement will be reflected for the first time in the fall 2019 Quarterly Refresh for the Inpatient Rehabilitation Facility (IRF) Compare website, and the related August 2019 IRF Provider Preview Reports.

Background

  • The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) directed the Secretary to specify and publicly report measures reflecting successful discharge to community for use in the IRF QRP.
  • The IRF QRP DTC measure was finalized in the Fiscal Year 2017 IRF PPS Final Rule. Confidential feedback reports were distributed to IRF providers in fall 2017 and the measures were first displayed on the IRF Compare website in fall 2018.
  • For the fall 2019 public display refresh of the DTC measure, and in future years, CMS has refined the method by which we assign providers to performance categories to align with the claims-based Potentially Preventable Readmissions measures in the IRF QRP and the Hospital-Wide Readmission measure in the Inpatient QRP.
  • Our revised methodology results in greater variation in performance categories, allowing better discernment of provider performance, including those that underperform or overperform considerably compared with the national rate. This refinement will be reflected in the fall 2019 Quarterly Refresh of the IRF Compare website, as well as the August 2019 IRF Provider Preview Reports.

May 30, 2019

Publication of Potentially Preventable Readmission Measures for the Post-Acute Care Quality Reporting Programs (QRPs)

Beginning fall 2019, CMS will publicly display measure results on the Inpatient Rehabilitation Facility Compare website for the following two measures: the Potentially Preventable 30-Day Post-Discharge Readmissions and Potentially Preventable Within-Stay Readmissions measures adopted for the Inpatient

Rehabilitation Facility (IRF) Quality Reporting Program (QRP). We postponed publishing these measures in late 2018 to allow more testing to ensure they provide a reliable, accurate picture of provider performance on quality, in line with CMS’s Meaningful Measures Initiative to address high-priority areas for quality measurement with measures that will help improve patient outcomes while minimizing provider burden. We have since completed this additional testing and have refined the method for assigning providers to performance categories, in which their performance level is compared to the national rate.

Background

  •  The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 directs the Secretary to specify a measure that reflects all-condition risk-adjusted potentially preventable hospital readmission rates for use in the IRF QRP. The IMPACT Act also requires the Secretary to publicly report provider performance on resource use and other measures, including measures to reflect all-condition risk-adjusted potentially preventable hospital readmission measures.
  •  CMS developed a potentially preventable 30-day readmission measure for the IRF QRP to meet the resource use and other measures domain as mandated by the IMPACT Act. CMS also developed a potentially preventable within-stay measure for the IRF QRP.
  • Since potentially preventable readmission rates are relatively low, we conducted additional testing to ensure that these measures reliably assess a provider’s performance on quality. We postponed publishing these measures while we were conducting this additional testing.
  •  We have since completed our additional testing and will publish these measures on the IRF Compare website for the September 2019 IRF Compare Quarterly Refresh.
  • As a result of the additional testing, we have refined our method for assigning providers to performance categories, which indicate their level of performance compared to the national rate. This refinement will also be reflected in both the September 2019 IRF Compare Quarterly Refresh and the June 2019 Provider Preview Reports.ATE

March 6, 2019

IRF Compare Quarterly Refresh

The March 2019 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including updated quality measure results based on data submitted to CMS between Quarter 2 2017 – Quarter 1 2018, is now available.

Please visit the IRF Compare website to view the updated quality data.

 

March 4, 2019 IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available.  The data contained within the Preview Reports is based on quality data submitted by IRFs between Quarter 3 – 2017 and Quarter 2 – 2018, and reflects what will be published on IRF Compare during the June 2019 refresh of the website. Providers have until April 3, 2019 to review their performance data. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

For more information:

IRF QRP Public Reporting Archives