Reconsideration Requests

About this Page

The Reconsideration Requests webpage provides information and updates related to the annual reconsideration process for the Hospice Quality Reporting Program (HQRP) Annual Payment Update (APU) determinations. On this page, you will find guidelines and processes for submitting reconsideration requests.

For questions related to content posted on this page, please contact the Reconsideration Help Desk at HospiceQRPReconsiderations@cms.hhs.gov.

For disasters impacting the Post-Acute Care Quality Reporting programs, a disaster-specific memo will be posted to the Downloads section below with additional information, including impacted counties and quality reporting quarters.

Reconsideration Request Overview

Any hospice determined to be non-compliant with the HQRP requirements may be subject to a reduction in their APU that becomes effective on October 1. Hospices are subject to a 4% reduction in their APU for failure to meet the requirements for the HIS and/or the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey. Starting with FY 2024, the penalty increases to a 4% reduction in APU reduction. For example, calendar year (CY) 2023 data affects federal fiscal year (FY) 2025 payments.

Any hospice found non-compliant will receive a letter of notification, which will include instructions for requesting reconsideration of this decision.

Calendar Year (CY) Data Impacts Fiscal Year (FY) APU Overview

• CY = January 1- December 31 and FY = October 1- September 30
• During the CY, hospices must submit and have accepted their HIS and CAHPS®) Hospice Survey data,
• The FY is when payment is impacted. Hospices are subject to a 4% reduction in their APU for failure to meet the requirements for HIS and/or CAHPS® Hospice Survey,
• NOTE: The HIS and CAHPS® have separate requirements for HQRP compliance. You must be compliant with both HIS and CAHPS® in the CY to be compliant with HQRP and receive your full APU each FY. HIS + CAHPS®= HQRP,
• For further training on this topic, please see the Hospice Quality Reporting Training – Training and Education Library webpage and specifically the November 14, 2019, webinar, Success with the HQRP: Putting the Pieces Together to Meet Compliance. Resources are included in this webinar.

Calendar Year Compliance Rules and Fiscal Year Payment Impacts

Background

The HQRP includes compliance with the requirements for the Hospice Item Set (HIS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). In the “FY 2016 Hospice Wage Index Final Rule” (79 FR 50486 through 50487), the Centers for Medicare & Medicaid Services (CMS) finalized the Fiscal Year (FY) 2017 HQRP requirements. Hospices must collect HIS data for all events beginning January 1, 2015, and after. Likewise, in the “FY 2014 Hospice Wage Index and Payment Rate Update” final rule (78 FR 48233), CMS stated they would start the national implementation of the CAHPS®. Beginning with the calendar year 2015 (FY 2017), CMS considers both HIS and CAHPS® survey data submitted by hospices to CMS, beginning on or after January 1, through December 31, to determine the APU compliance threshold.

What is Reconsideration?

Reconsideration is a request for a review of the initial non-compliance decision prior to the four (4) percentage point reduction in the hospice’s APU taking effect on October 1. For HQRP, hospices can be found to be non-compliant if they are non-compliant with:

• Either HIS or CAHPS® Hospice Survey, OR
• Both HIS and CAHPS® Hospice Survey.

When Would a Hospice Submit a Reconsideration Request?

Hospices may file for reconsideration if they receive a letter of HQRP non-compliance and believe the finding of non-compliance is in error. Hospices that want to have their circumstances reviewed by CMS must file a reconsideration request.

Note: If a hospice is found non-compliant with HQRP, then it is subject to the 4% reduction in APU beginning with FY 2024. This means even if the hospice thinks it meets an exception such as newness or related to a disaster, it must prove it during the reconsideration process by providing appropriate documentation to support the hospice’s position.

Review the Reconsideration Requests webpage for details about how to submit a reconsideration. Failure to submit a timely HQRP reconsideration automatically subjects any hospice non-compliant with HQRP to the 4% APU reduction for that fiscal year.

Reconsideration Request Process

CMS will notify hospices that are non-compliant with HQRP in two ways;

• The Medicare Administrative Contractors (MACs), and
• An electronic letter via the QIES - Certification and Survey Provider Enhanced Reporting (CASPER) system.

Hospices should look for the letter and be sure to access their CASPER system since either letter serves as notice of HQRP non-compliance. Hospices that receive a letter of non-compliance must submit a request for reconsideration to CMS within thirty (30) days after the date documented on 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

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

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

The email request must include the following information related to HIS and/or CAHPS® Hospice Data:

• The Hospice CMS Certification Number (CCN)
• The Hospice Business Name
• The Hospice 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 hospice belief that non-compliance is in error, or evidence of the impact of extraordinary circumstances that prevented timely submission of data

The request for reconsideration must be accompanied by supporting documentation demonstrating compliance with QRP data. CMS will be unable to review any requests that fail to provide the necessary documentation nor accept any files that are larger than 20 MB (megabytes). Supporting documentation may include any or all of the following:

• Proof of timely submission,
• Email communications,
• Data submission reports from QIES,
• Proof of previous waiver approvals (including disaster exceptions/exemptions), and
• CCN Activation Letter

IMPORTANT:

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

Any documentation submitted for review that includes PHI or PII will not be accepted or reviewed for reconsideration. Please redact any PHI/PII prior to sending. If any documents included in a reconsideration request contain PHI/PII, the entire request will be rejected.

Review Data Submissions---Helpful Information

Helpful information on how to review the submitted data is available on the HQRP webpages.

Reconsideration Request Process Timeline

Estimated reconsideration process timeline:

• July - CMS issues notices of non-compliance to hospices that failed to meet the hospice quality reporting requirements.
• July-August - Reconsideration requests are due to CMS thirty (30) days from the date of the notification of non-compliance.
• July-August - CMS provides an email acknowledgment within five (5) business days upon receipt of the reconsideration request.
• September - CMS notifies hospices of the Agency’s decision on the reconsideration requests.
• October 1- Any hospice determined to be non-compliant is subject to the 4% reduction in their APU for that fiscal year.

Response from CMS

CMS will provide an email acknowledgment of receipt of the reconsideration request. CMS will notify the hospice of its decision to any reconsideration via the MACs and also an electronic letter via the QIES - Certification and Survey Provider Enhanced Reporting (CASPER) system. Hospices should look for the letter and be sure to access their CASPER system since either letter serves as notice of CMS’ decision.

Filling an Appeal

Hospices dissatisfied with the 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 webpage. You must follow the instructions listed on that website to file with the PRRB.

If the amount in controversy is at least $1,000, but less than $10,000, then Federal Specialized Services (“FSS”) will manage the dispute as an Intermediary Hearing. Requests for an Intermediary Hearing should be sent electronically to intermediary@fssappeals.com.  

Resources Available

Resources are available in the Downloads section and other useful information can be found on this website, such as the Best Practices and Education and Training Library webpages.

Swingtech is a CMS contractor. Swingtech sends informational messages related to hospice reconsideration issues quarterly. Their latest outreach communication can be found in the Downloads section of this page. If you want to receive Swingtech’s quarterly emails, add or update the email addresses to which these messages are sent by emailing QRPHelp@swingtech.com and include your facility name and CCN along with any requested updates.

For More Information

For additional assistance, hospices may submit questions related to the reconsideration request to: HospiceQRPReconsiderations@cms.hhs.gov.

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