CMK Home Health Agency Inc. of Illinois will receive a 2 percent reduction in its 2012 market basket payment because a Centers for Medicare and Medicaid Services (CMS)-approved survey vendor did not timely submit quality reporting survey data required by the Deficit Reduction Act (DRA) of 2005. A Provider Reimbursement Review Board (PRRB) decision issued Aug. 22 concluded that it is the home health agency (HHA) provider’s responsibility to monitor its chosen vendor to ensure data is submitted timely without problems. The board said it has no flexibility to waive the penalty regardless of circumstances because there is no statutory or regulatory allowance for relief. Background Between 2005 and November 2009, quality-reporting requirements under the DRA have expanded to include additional quality measures and certain forms, and survey tools have been created by CMS to replace older Outcome and Assessment Set forms, referred to as OASIS. In 2009, providers were required to begin reporting quality measures surrounding patient experiences with home health services and through a new survey tool referred to as Consumer Assessment of Healthcare Providers and Systems (CAHPS). After an extensive period of CMS training vendors to administer the surveys, HHAs would contract with these CMS-approved vendors for […]
CMK Home Health Agency Inc. of Illinois will receive a 2 percent reduction in its 2012 market basket payment because a Centers for Medicare and Medicaid Services (CMS)-approved survey vendor did not timely submit quality reporting survey data required by the Deficit Reduction Act (DRA) of 2005.
A Provider Reimbursement Review Board (PRRB) decision issued Aug. 22 concluded that it is the home health agency (HHA) provider’s responsibility to monitor its chosen vendor to ensure data is submitted timely without problems. The board said it has no flexibility to waive the penalty regardless of circumstances because there is no statutory or regulatory allowance for relief.
Background
Between 2005 and November 2009, quality-reporting requirements under the DRA have expanded to include additional quality measures and certain forms, and survey tools have been created by CMS to replace older Outcome and Assessment Set forms, referred to as OASIS. In 2009, providers were required to begin reporting quality measures surrounding patient experiences with home health services and through a new survey tool referred to as Consumer Assessment of Healthcare Providers and Systems (CAHPS).
After an extensive period of CMS training vendors to administer the surveys, HHAs would contract with these CMS-approved vendors for the actual reporting of the data.
On Sept. 16, 2011, the Medicare Administrative Contractor (MAC) for CMK informed the HHA that it would receive the reduction in reimbursements because it had not complied with data reporting requirements. It had not submitted the CAHPS data in a timely manner. CMK requested a redetermination and was denied. CMK appealed, leading to the PRRB decision.
Should Providers Be Punished for a Government-Approved Vendor’s Error?
CMK argued that it should not be punished because it had complied with the regulations in choosing, designating, and authorizing a CMS-approved vendor to submit the data and that it had submitted the necessary patient records and other data to the vendor in a timely fashion so that it could meet reporting requirements on behalf of CMK. The vendor failed to meet its obligation.
CMK also provided an open letter from the vendor in which “the vendor acknowledged that it was solely at fault for the Provider not meeting the quality data submission requirements that were linked to the CY 2012 annual payment update for the home health prospective payment system.”
Ultimately, the PRRB noted that the home health CAHPS guidelines and protocols manual required CMS to ensure compliance with privacy rules but not to ensure vendor performance on its contracts with individual providers. In the written decision, the MAC representative argued that CMK is seeking relief from the wrong party—it should seek relief instead from the contracted vendor that did not meet its contractual obligations.
The PRRB said it does not have authority to grant equitable relief to the HHA. The good news is that the 2 percent reduction applies only during 2012. CMK has an opportunity to correct the problem for the next reporting period.
Takeaway: Regardless of the issue, whether it is a reduction in payment or an allegation of fraud and abuse, the laboratory or provider is ultimately responsible to ensure compliance with laws, rules, and regulations by its contracted vendors or agents.
