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IRF Quality Reporting Reconsideration and Exception & Extension

The Reconsideration webpage provides information and updates related to the reconsideration process for the IRF QRP. On this page, you will find guidelines and processes for submitting reconsiderations requests and requests for exceptions and exemptions.

IRF QRP: Natural Disaster Protocol

IRFs affected by natural disaster(s) in counties that are identified through the Federal Emergency Management Agency (FEMA) as “Designated Areas” will be provided guidance and further information via this webpage with respect to data submission requirements, as it becomes available.

In addition, details and materials are also available on the CMS Emergency Response and Recovery webpage.

Please note- designated areas may be updated to add affected areas by natural disasters. Please continue to check back frequently for updates.

Updates

Notice: February 23, 2018

Please review the Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to Hurricane Nate.

Notice: February 22, 2018

Please review the Disaster Exceptions/Exemptions for Medicare Certified Providers memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to the December California Wildfires (FEMA DR-4353).

Notice: November 02, 2017

Please review the Disaster Exceptions/Exemptions for Medicare Certified Providers memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to the Northern California Wildfires.

September 28, 2017

Please review the Hurricane Maria - Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to Hurricane Maria.

Notice: September 14, 2017

Please review the Hurricane Irma - Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to Hurricane Irma.

Notice: August 31, 2017

Please review the Hurricane Harvey - Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding memo located in the Download section below for additional information regarding the data reporting exceptions and exemptions related to Hurricane Harvey.

NOTICE: November 16, 2016

Please review the Extraordinary Circumstances Extension due to Hurricane Matthew November located in the Download section below for additional information regarding the blanket exemption for data submission related to Hurricane Matthew.

Reconsideration

Reconsideration Request Overview

In the FY 2017 Inpatient Rehabilitation Facility (IRF) Final Rule 80 FR 47125 through 47126, the Centers for Medicare & Medicaid Services (CMS) finalized the IRF Quality Reporting Program (QRP) requirements. Any IRF determined to be non-compliant with the IRF QRP requirements may be subject to a two (2) percentage point reduction in their annual payment update (APU).

Any IRF found non-compliant will receive a letter of notification from their Medicare Administrative Contractor (MAC), which will include instructions for requesting reconsideration of this decision. In addition, all Medicare-certified IRF compliance letters will be distributed electronically into the Certification And Survey Provider Enhanced Reports (CASPER) folders within the Quality Improvement and Evaluation System (QIES for each IRF to access. This letter also include the reason(s) for failing APU compliance. Instructions to download files from QIES may be found at https://www.qtso.com/irfpai.html.

What is Reconsideration?

Reconsideration is a request for a review of the initial compliance determination for a given IRF, for a given fiscal year (FY).

When Would an IRF Submit a Reconsideration Request?

IRFs may file for reconsideration if they believe the finding of non-compliance is in error, or they have evidence of the impact of extraordinary circumstances which prevented timely submission of data.

Important Note: A request for reconsideration due to a deficiency in the IRF reporting of data as required in the IRF QRP due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §412.614.

Reconsideration Request Process

To apply for reconsideration, the IRF must receive a CMS letter of non-compliance. An IRF disagreeing with the payment reduction decision may submit a request for reconsideration to CMS within thirty (30) days from the date at the top of the non-compliance notification letter distributed electronically using QIES. CMS will not accept any requests submitted after the thirty (30) day deadline.

Create a Reconsideration Request

Please note: The only method for submitting reconsideration requests is via email. Requests submitted by any other means will not be reviewed for reconsideration.

IRFs are required to submit their request to CMS via email with the subject line: “IRF ACA 3004 Reconsideration Request” and include the IRF CMS Certification Number (CCN) (e.g., IRF ACA 3004 Reconsideration Request, XXXXXX). The request must be sent to the following email address: IRFQRPReconsiderations@cms.hhs.gov.

The email request must contain 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
  • CMS identified reason(s) for non-compliance from the non-compliance notification letter
  • Information supporting the IRF belief that either non-compliance is in error, or evidence of the impact of extraordinary circumstances which prevented timely submission of data

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
  • Email communications
  • Data submission reports from the Quality Improvement Evaluation System (QIES)
  • Data submission reports from the National Healthcare Safety Network (NHSN)
  • Proof of approved exception or extension for the reporting time frame
  • Copy of the CCN activation letter
  • Other documentation supporting the rationale for seeking reconsideration

IMPORTANT:

Never include patient information (i.e. protected health information (PHI), patient identifiable information (PII), or other Health Insurance Portability and Accountability Act (HIPAA) violation) in the documentation being submitted to CMS for review.  Submitting patient-level data or protected health information may be a violation of your facilities’ policies and procedures as well as violation of federal regulations (HIPAA).

Review Data Submissions

For FY 2019 payment determination, IRFs are required to submit data for the following quality measures:

  • NQF #0138 National Health Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure via the Centers for Disease Control and Prevention (CDC) NHSN for the reporting period of January 1, 2017, through December 31, 2017
  • NQF #0431 Healthcare Personnel Influenza Vaccination through the CDC NHSN for the reporting period of October 1, 2017, through March 31, 2018
  • NQF #1716 NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure via the CDC NHSN for the reporting period of January 1, 2017, through December 31, 2017
  • NQF #1717 NHSN Facility-Wide Inpatient Hospital-Onset Clostridium Difficile Infection (CDI) Outcome Measure via the CDC NHSN for the reporting period of January 1, 2017, through December 31, 2017
  • NQF #0678 Percent of Residents or Patients with Pressure Ulcers That are New or Worsened (Short-Stay) via the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) for the reporting period of Januarary 1, 2017, through December 31, 2017
  • NQF #0680 Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) via the IRF-PAI for the reporting period of July 1, 2016, through June 30, 2017.
  • NQF #0674 Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) for the reporting period of January 1, 2017 through December 31, 2017
  • NQF #2631 Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function for the reporting period January 1, 2017 through December 31, 2017
  • NQF #2633 IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients for the reporting period January 1, 2017 through December 31, 2017
  • NQF #2634 IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients for the reporting period January 1, 2017 through December 31, 2017
  • NQF #2635 IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients for the reporting period January 1, 2017 through December 31, 2017
  • NQF #2636 IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients for the reporting period January 1, 2017 through December 31, 2017.

Reconsideration Request Process Timeline

Below is the estimated reconsideration process timeline for FY 2019 payment determination:

  • June - July 2018 - CMS issues notices of non-compliance to IRFs that failed to meet quality reporting requirements via letter from the MACs as well as distributed electronically using QIES.
  • July - August 2018 - Reconsideration requests are due to CMS thirty (30) days from the date on the notification of non-compliance distributed electronically into the CASPER folders in QIES.
  • July - August 2018 - CMS provides an email acknowledgement within five (5) business days upon receipt of reconsideration request.
  • September 2018 - CMS notifies IRFs of the Agency’s decision on the reconsideration requests via letter from the MACs as well as distributed electronically into the CASPER folders in QIES.

Filing an Appeal

IRFs dissatisfied with the IRF QRP reconsideration ruling may file a claim under 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board [PRRB] appeal). Details are available on the CMS.gov
 
PRRB Review Instructions website.

 

Exception and Extension

Exception and Extension Requests Overview

CMS provides IRFs an opportunity to request an exception or extension from the program’s reporting requirements in the event they were unable to submit quality data due to extraordinary circumstances beyond their control. IRFs affected by a natural or man-made disaster or other extraordinary circumstances may request an exception or extension by filing a Request for Reconsideration Due to Disaster or Extraordinary Circumstance.

Important Note: A request for reconsideration due to a deficiency in the IRF reporting of data as required in the IRF QRP due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §412.614.

Submission Exception and Extension Process in Cases of Disaster or Extraordinary Circumstances

All IRFs requesting an exception or extension must submit the request within ninety (90) days of the event. CMS may grant the exception or extension for one or more quarters. CMS may also grant the exception or extension to IRFs that have not requested one when an extraordinary circumstance, such as an act of nature, affects an entire region or locale. CMS will communicate through routine channels when such determination is made.

IRFs must request an exception or extension via email with the subject line, “Disaster Exception or Extension Request” and send it to IRFQRPReconsiderations@cms.hhs.gov. The email must include the following information:

  • IRF CCN
  • IRF Business Name
  • IRF Business Address
  • CEO or CEO-designated personnel contact information including name, email address, telephone number, and physical mailing address
  • Description of the event (examples provided above) associated with the reason for requesting the exception or extension
  • A date when the IRF believes that it will again be able to submit IRF QRP data and a justification for the proposed date.

Response from CMS

CMS will provide an email acknowledgement upon receipt of the exception or extension request. CMS will notify the CEO or CEO-designated contact provided in the request with the decision, via USPS mail and email.

For More Information

For additional assistance, IRFs may submit questions related to the reconsideration or IRF QRP exception and extension request to: IRFQRPReconsiderations@cms.hhs.gov.

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