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Hospital COVID-19 Reporting: HHS Updates Guidance and CMS Details Enforcement

October 9, 2020

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CONTACTS
Phoebe Ramsey, Sr. Regulatory Analyst, Quality & Payment Policy
Gayle Lee, Director, Physician Payment & Quality

The Department of Health and Human Services (HHS) updated its guidance and FAQs for its requirements for daily hospital reporting of COVID-19-related data. In tandem, the Centers for Medicare and Medicaid Services (CMS) issued a memo, “Interim Final Rule Requirements and Enforcement Process for Reporting of COVID-19 Data Elements for Hospitals and Critical Access Hospitals (CAHs).”

The updated HHS reporting guidance:

  • Adds six new influenza fields (33-38) for voluntary reporting beginning Oct. 19 (noting intention of becoming mandatory in the future).
  • Clarifies that daily reporting is required for information in data fields 1-25, except for psychiatric and rehabilitation hospitals that may report those items weekly.
  • Reduces frequency of required reporting on supplies (items reported in data fields 26-32), which must now be reported once a week on Wednesdays.

The CMS memo details requirements and enforcement of the agency’s Sept. 2 Interim Final Rule, which included new Conditions of Participation (CoPs) for hospitals and CAHs to report the HHS-specified COVID-19-related data during the public health emergency (PHE). If a hospital fails to report the required data, it will be terminated from the Medicare and Medicaid programs.

The memo outlines an initial 14-week process before a hospital’s participation would be terminated:  

  • Establishes a multistep approach to enforcement for noncompliance as follows:
    1. Initial notice from CMS to hospitals that do not meet reporting requirements completely on a daily basis.
    2. Reminder notice three weeks after initial notice for continued failure to meet the reporting requirements.
    3. First enforcement notification letter will go out after a provider continually (for a period of six weeks) fails to meet reporting requirements and would give the provider one week to demonstrate compliance.
    4. Second enforcement notification letter within one week following the first enforcement notice giving one week to demonstrate compliance.
    5. Third and final enforcement notification letter within one week following the second enforcement notice for providers that have failed to meet the reporting requirements. This notification will include a 30-day notice of termination of the Medicare provider agreement if a provider fails to meet the reporting requirements within the 30-day timeframe.
  • Notes the first two steps of the enforcement process outlined above are only applicable from Oct. 2 through Nov. 13, 2020. Noncompliance identified after this period will begin with step 3 in the series of enforcement notifications.
  • Specifies that in the event a hospital or CAH is found to be in compliance, enforcement remedies will be rescinded and, if the provider subsequently demonstrates non-compliance in the future, a new enforcement action will begin from the start of the process.
  • Clarifies that noncompliance will be determined independently from health and safety surveys for all other CoPs.
     

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