LeadingAge Discusses Noncompliance Issues with CMS Quality Reporting Staff

Posted on September 18, 2018 by Jodi Boyne

LeadingAge recently met with the Centers for Medicare & Medicaid Services (CMS) regarding the Skilled Nursing Facility Quality Reporting Program (QRP) to help them better understand the noncompliance experience and identify process improvements to help reduce noncompliance in future years. 

CMS said that less than 2 percent of the 15,191 Skilled Nursing Facilities received a noncompliance letter. Roughly 50 percent of those organizations submitted a request for reconsideration and supporting documentation. 

CMS granted reconsideration for about half of the Skilled Nursing Facilities who requested it stating they had made a compelling argument demonstrating that they had been using the CASPER system reports but fell short in meeting the 80 percent threshold reporting requirement. Those organizations who were granted reconsideration will not be penalized the 2 percent off their Medicare Fee-For-Service rates. Skilled Nursing Facilities whose noncompliance was upheld still have an opportunity to appeal. 

The main reason for noncompliance was related to the functional assessment measure which is tied to completion of MDS items in Section GG. See A Crosswalk of the MDS items to the SNF QRP measures for more information about which MDS items can impact reporting on this and other MDS-based measures. When these sections are completed with a dash, they are considered not completed and therefore not counted as reporting this information.  

CMS shared that they are creating a new report in CASPER that will be released early Winter (likely January 2019), called an APU Threshold Report. This report will show, by MDS quality measure, the number of MDS assessments submitted and the number considered to be completed with a valid value so Skilled Nursing Facilities can better understand whether they are meeting or exceeding the required 80 percent reporting threshold. Skilled Nursing Facilities will be able to run these reports at any time. Each time the report is run it will capture the most recent data so if an organization makes corrections to its MDS submissions it will show up the next time the report is run. Skilled Nursing Facilities will have 4 ½ months from the end of a quarter to submit missing data or late MDS forms for that quarter. For example, MDS assessments submitted in the fourth quarter of 2018 will be able to corrected, submitted or updated until May 15, 2019. 

CMS recorded a July training session on the QRP program and will soon post it to its web site. One helpful portion of the training reviewed available reports in the CASPER system, where to find them and how they might be useful. We will publish more information when this recorded training is released.