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Tag: CMS Ruling

Quality Program Changes

While CMS is finalizing several of the proposed changes to the hospital quality reporting and payment programs, none of these changes represent significant structural or procedural changes to the programs.
Hospital Inpatient Quality Reporting (IQR)
CMS is making the following adjustments to the program:
  • Adopt the Hybrid Hospital-Wide All-Cause Readmission (Hybrid HWR) measure, beginning with two voluntary reporting periods running from 7/1/2021 to 6/30/2022 and from 7/1/2022 to 6/30/2023.
  • Adopt the Safe Use of Opioids – Concurrent Prescribing electronic clinical quality measure (eCQM), with a clarification and update, beginning with CY 2021 reporting period/FY 2023 payment determination.
  • Remove the Claims-based Hospital-Wide All-Cause Unplanned Readmission measure (HWR claims-only measure) beginning with the FY2026 payment determination.
  • Extend current eCQM reporting and submission requirements for both the CY2020 reporting (FY2022 payment) and the CY2021 reporting (FY2023 payment) periods.
  • Change eCQM reporting and submission requirements for the CY2022 reporting (FY2024 payment) period, such that hospitals would be required to report one self-selected calendar quarter of data for three self-selected eCQMs and the proposed Safe Use of Opioids eCQM.
  • Continue requiring that EHRs be certified to all available eCQMs used in the Hospital IQR program for the CY2020 and subsequent reporting periods.
CMS is not finalizing its proposal to adopt the Hospital Harm – Opioid-related Adverse Events eCQM.
Hospital Value Based Purchasing (HVBP)
CMS will now require that the HVBP program use the same data used by the HAC program for purposes of calculating the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) Healthcare-Associated Infection (HAI) measures beginning with the CY2020 data collection, when the hospital IQR program will no longer collect data on those measures.
CMS is not adding or removing any measures for the FY2022 and FY2023 program years. However, CMS will be establishing new performance standards for FY2024 and FY2025.
Hospital Readmission Reduction (HRR)
CMS will adopt the following adjustments to the program:
  • Establish the performance period for the FY 2022 program year.
  • Adopt a measure removal policy that aligns with the policies for other quality programs.
  • Update the definition of “dual-eligible” as a beneficiary who has full benefit status in both the Medicare and Medicaid programs for the month the beneficiary was discharged, except for those beneficiaries who die in the month of discharge, who will be identified using the previous month’s data.
  • Adopt a process to make nonsubstantive changes to the payment adjustment factors, which would include updated naming or locations of data file or minor discrepancies, but which would not include different methodologies to use data or the use of a different component in the methodology.
  • Update 42 CFR 412.152 and 412.154 to reflect policies finalized in previous Rules.
Hospital Acquired Conditions (HAC)
CMS will make the following adjustments to the program:
  • Adopt a measure removal policy that aligns with the policies for other quality programs.
  • Clarify policies for validating CDC NHSN HAI measures.
  • Adopt the collection periods for the FY2022 program year.
    • CMS PSI 90 measure – 24-month period from 7/1/2018 to 6/30/2020
    • CDC NHSN HAI measures – 24-month period from 1/1/2019 to 12/31/2020.
  • Update 42 CFR 412.172(f) to reflect policies finalized in the FFY2019 IPPS Final Rule.
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CMS Ruling 1498-R2 – Revised SSI Issuances 1988-2005

From: CMS DSH Website – 4/23/15

CMS posted several new data files on their DSH SSI website location.  Most significant of these postings is an issuance of a revised ruling regarding the handling of SSI for DSH purposes titled 1498-R2.  This issuance was precipitated by the “Catholic Health” decision in the D.C Circuit court related to the exclusion of Medicare non-covered days in the SSI ratio.

This revised ruling can be found by clicking the link above and scrolling to the end of the download section.  The application of this revised ruling is only for providers that either have not had a finalized cost report issued or have properly pending appeals between 1988 – 2005 (ending on or before October 1, 2014).  Included as part of this revised ruling are revised SSI files all titled “R2” covering 1988-2005.

CMS states in the application of this revised ruling:

“This modification and amendment of CMS Ruling 1498-R allows providers to elect whether to receive Medicare-SSI fractions on the basis of “total days,” or “covered days,” but it does not alter any other provisions of CMS Ruling 1498-R, including the mechanism for implementation by the administrative tribunals; applicability to cost reports not yet finally settled by an initial notice of program reimbursement (NPR); the Ruling’s general provision for unitary relief on all three DSH issues; and the determination that CMS Ruling 1498-R is not an appropriate basis for reopening of any final determination of the Secretary or a contractor or an decision by a reviewing entity.”

We have been expecting this issuance by CMS and will be evaluating the revised issuance for all of our clients with appeals properly established for the timeframes described above.  The revised SSI issuances are not necessarily an improvement over the original issuances.

CMS Ruling 1498-R2 – Revised SSI Issuances 1988-2005

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DSH SSI – Revised Ruling 1498-R2 – Toyon Client Memo

To:        Medicare DSH Appeal Clients

From:   Thomas P. Knight, President

Re:       Medicare DSH Appeal Update


We are pleased to report there has been a breakthrough on the Medicare SSI Ratio appeals for cost reports containing services prior to 10/1/04.  See the attached new ruling CMS-1498-R2 dated April 22, 2015.  This ruling has come about due to multiple court decisions related to Medicare DSH appeals.

Specifically, CMS has now published corrected SSI ratios on both a total patient day and covered patient day basis, and will allow Providers to choose which method they want to use.  Further, it appears that CMS will also allow Providers to realign their SSI ratios to their cost reporting period from the federal fiscal year basis normally used.  Further instructions regarding this are supposed to be released.

We are in the process of analyzing the new SSI ratios for all of our clients and will be identifying the best option for each facility.  We will also be requesting the supporting MedPar data for each applicable year to determine if there are any further discrepancies in the data as well as to determine whether realignment from federal fiscal year to hospital fiscal year is beneficial.

Please note that these corrected SSI ratios only apply to those fiscal years where an open Medicare appeal on the SSI issue exists or where the SSI Ratio appeal had been remanded to the Intermediary for action.

Upon completion of our initial review, we will notify each client of the potential reimbursement impact.  Due to the large number of clients, this will take a little while, but we will get it accomplished as soon as possible.

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