Reconsideration Overview

Process Regarding FY 2014 APU Decisions

Beginning in Fiscal Year (FY) 2014, the Centers for Medicare & Medicaid Services (CMS) will notify hospitals subject to annual payment reduction in two phases. In the first phase, CMS will notify hospitals in March 2013 that did not meet selected clinical process of care and healthcare-associated infection submission requirements.

In the second phase, CMS intends to notify hospitals that did not meet other program requirements in May 2013. Specific requirements for each phase are detailed below.

CMS provides hospitals the opportunity to request a reconsideration of these adverse decisions. CMS encourages all hospitals to continue submitting all remaining calendar year 2012 data as Hospital Inpatient Quality Reporting (IQR) data is used for Hospital Value Based Purchasing baseline and/or performance rates.

Hospitals requesting IQR Program reconsideration from CMS must submit their request within 30 days following the date identified on Hospital IQR Program APU notification letter.

The request must identify the hospital’s specific reason(s) for believing the Hospital IQR Program requirements were met and why the hospital should receive the full FY 2014 Inpatient Prospective Payment Systems (IPPS) Annual Payment Update (APU). When the hospital's request is related to validation, the hospital must submit a completed Validation Review for Reconsideration Request form, along with the reconsideration request.

First phase of notification

In March 2013, CMS will review hospital data accepted for the first three quarters of Calendar Year (CY) 2012 for the FY 2014 APU. The specific requirements that will be addressed are one or more of the following:

  • Submit complete data for each required clinical process measures by the posted submission deadlines.
  • Submit aggregate initial patient population and sample size counts by the posted submission deadlines.
  • Submit Healthcare Associated Infection (HAI) data to National Healthcare Safety Network (NHSN) by the posted submission deadline.

Second phase of notification

In May 2013, CMS will review hospital data accepted for the Fourth Quarter of CY 2012 for the FY 2014 APU. The specific requirements that will be addressed are one or more of the following:

  • Identify a QualityNet Security Administrator who follows the registration process located on the QualityNet website, regardless of how the hospital submits data (directly or by vendor).
  • Complete a Notice of Participation.
  • Submit complete data for each required clinical process measure by the posted submission deadlines.
  • Submit aggregate initial patient population and sample size counts by the posted submission deadlines.
  • Continuously collect and submit Hospital Consumer Assessment of Healthcare Providers (HCAHPS).
  • Submit Healthcare Associated Infection (HAI) data to National Healthcare Safety Network (NHSN) by the posted submission deadline.
  • Complete the Structural Measure Questions.
  • Meet Validation requirements for the clinical process measures.
  • Complete the Data Accuracy and Completeness Acknowledgement.

CMS will officially respond to the reconsideration request submitted by each hospital.

Filing an appeal

When a hospital is dissatisfied with the result of CMS’s reconsideration, the hospital 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. An appeal can be filed with the Provider Reimbursement Review Board (PRRB) only after the hospital has submitted a request for reconsideration and received a decision on the request.

For more information

For assistance in completing and/or submitting the Reconsideration Request, refer to the following reconsideration resources.

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