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FY 2021 AND 2022HOSPICE QUALITYREPORTING PROGRAMSuccess with the HQRP:Putting the Pieces Together toMeet Compliance --Resources IncludedCindy Massuda, HQRP CoordinatorDebra Dean-Whittaker, CAHPS Hospice SurveyLead

GLOSSARYAcronymTermAPUAnnual Payment UpdateCAHPS CMSHospice Consumer Assessment ofHealthcare Providers and Systems CAHPS SurveyCenters for Medicare & Medicaid ServicesCOPConditions of ParticipationCYCalendar YearFYFiscal YearHISHospice Item SetHQRPHospice Quality Reporting Program2

WHAT ARE THE REQUIREMENTS FORTHE HOSPICE QUALITY REPORTINGPROGRAM (HQRP)? All Medicare-certified hospice providers must comply with both HIS and CAHPS reporting requirements. NOTE: The data collection year is based on the Calendar Year (CY) but the Payment isbased on the Fiscal Year (FY). For more in-depth training on Hospice Quality Reporting, you can find and access priorpresentations on the Training and Education Library web page. You can also look at theHospice Quality Reporting Program web page for more general information.3

CY AND FY DEFINEDCY January 1December 31FY October 1September 30 During the CY, hospices must submit and have accepted their HIS and CAHPS HospiceSurvey data. The FY is when payment is impacted. Hospices are subject to a 2% reduction in their APU forfailure to meet the requirements for HIS and/or CAHPS Hospice Survey. NOTE: HIS and CAHPS have separate requirements for HQRP compliance. You must becompliant with both HIS and CAHPS in the CY to be compliant with HQRP and receive yourfull APU each FY. HIS CAHPS HQRP4

HQRP TIMEFRAMES The HQRP is a pay for reporting program. HIS and CAHPS have separate requirements for HQRP compliance. You must becompliant with both HIS and CAHPS in the CY to be compliant with HQRP and receiveyour full APU each FY. HIS CAHPS HQRPFY PaymentCY Data(Jan 1- Dec 31) 5Submit and Accept HIS Datao Meet the 90% ThresholdCollect and SubmitCAHPS Hospice Data(Oct 1- Sept 30) Payment is impacted Hospices are subject to a 2% reduction in theirAPU for failure to meet the HQRP requirementsCY 2020FY 2022CY 2021FY 2023CY 2022FY 2024CY 2023FY 2025

WHAT IS THE HQRP COMPLIANCECYCLE?The cycle of data collection and compliance determinations follow the CY while paymentimpact follows the FYHospice’s DataCollection & Submissions(HIS and CAHPS )CY 2020CMS onPayment ImpactAPU in Effect for FY 2021(October 1, 2021 - September 30, 2022)Non-Compliant HospiceCompletes ReconsiderationRequests Within 30 DaysCY 20216CMS DeliversReconsiderationResults

HOW AND WHEN HQRPREQUIREMENTS IMPACT PAYMENT--SUMMARY Meeting the HIS Requirements, including the 90% submission thresholdand CAHPS Hospice Survey Requirements during the Calendar Yearcollection year will impact payment in the Fiscal Year two years later. We encourage you to review: January 2019 Hospice Quality ReportingProgram (HQRP): Achieving a Full Annual Payment Update (APU)Webinar.7

HOSPICE ITEMSET (HIS)

HOSPICE ITEM SET (HIS)HQRP9HISCAHPS

WHAT DO I NEED TO DO TO MEETTHE HIS SUBMISSION THRESHOLD?Timely submission and acceptance of the HIS data must occur for allpatients within 30 days of admission and discharge at least 90% of thetime in order to meet the timeliness compliance threshold.It is important to note that timely submission alone does not equalcompliance. Data must also be accepted. It is recommended that hospicessubmit data within 7-14 days to be sure of acceptance by the 30 daydeadline.10

MORE ABOUT HIS SUBMISSION ANDACCEPTANCE Hospice agencies should submit HIS data for all for ALL patient admissions and discharges,regardless of the payer, patient’s age, or the location of the receipt of hospice service. Hospices are encouraged to use the Hospice Submission User's Guide available on the:Hospice User Guides & Training web page of the QTSO website. This guide has usefulinformation about the submission, acceptance, and modification of data, in addition totroubleshooting errors. Click here for more information about the HIS. Valuable training on this topic is also locatedhere: HQRP Data Submission Requirements and Reports.11

HIS 90% THRESHOLDAll hospices meeting the 90% threshold requirement means timely reporting of 90% of theirHIS data.Note: Hospices must meet ALL HQRP Requirements to avoid the 2% reduction in their APU.Threshold Compliance today pays off in the future.12HIS Records FromSubmission ThresholdPayment YearCY 201990%FY 2021CY 202090%FY 2022CY 202190%FY 2023

CONSUMERASSESSMENT OFHEALTHCAREPROVIDERS ANDSYSTEMS (CAHPS )HOSPICE SURVEY

CONSUMER ASSESSMENT OFHEALTHCARE PROVIDERS ANDSYSTEMS (CAHPS ) HOSPICE SURVEYHQRP14HISCAHPS

WHAT ARE THE CAHPS REQUIREMENTS?As with the HIS, the data collection year runs from January 1through December 31.ALL Medicare-certified hospices must participate monthly.More detailed information can be found here: CAHPS Hospice Survey.15

CAHPSCAN OUR HOSPICE SWITCHSURVEY RESEARCH VENDORS? Yes you can, but . It is important to handle the process correctly. Not following the correct process is a known risk for failingthe APU. A 2% reduction.16

SWITCHING CAHPS SURVEY VENDORS:RESTRICTIONSYou may switch vendors only at the beginning of a calendar quarter. Thecalendar quarters correspond to the month of patient death.Q1Q2Q3Q4January 1April 1July 1October 1Note: You may not switch vendors in the middle of a quarter.17

Switching CAHPS Survey Vendors: ProcessHere iswhathappenswhen youswitch asof Jan 1OCTNOV2019Start with new vendor.Send sample to new vendor starting with Jan 2020 deaths.New vendor starts data collection for Jan 2020 deaths.New vendor starts submitting OVDECAPU in Effect for FY 2021Old vendor submits data for Oct – Dec 2019 deaths.Old vendor is collecting dataFrom Oct – Dec 2019 deaths.18

SWITCHING CAHPS SURVEYVENDORS, CONT. 19Your hospice must have a survey vendor collect and submit data forevery month of the calendar year - no skipping months.You must authorize a vendor to submit your data.You must submit a vendor authorization form.Only one vendor can be authorized to submit data at a time.If you are switching, you have two vendors collecting andsubmitting data for you.This is why you need to contact us.We will help you navigate the process

SWITCHING CAHPS SURVEYVENDORS: WHAT TO DO FIRST The most important thing for your hospice to do is contact usfirst:o Email us at: hospicecahpssurvey@HSAG.com orcall:1-844-472-4621.o Our technical assistance team will be glad to help you.o Carefully following their instructions will increase theprobability that you switch successfully.20

CHECKLISTSUMMARY

CHECKLIST SUMMARY22

FY 2022 HQRP COMPLIANCECHECKLIST (BASED ON CY 2020 DATA)23HISCAHPS Submit at least 90% ofall HIS records within 30days of the event date(patient’s admission ordischarge) for patientadmissions/dischargesoccurring CY: 1/1/2012/31/20.Ongoing monthlyparticipation (CY: 1/1/2012/31/20) in the HospiceCAHPS survey where anapproved 3rd party vendorsubmits Hospice CAHPS data according to thequarterly deadlines.

HOW CAN YOUR HOSPICE HELPENSURE COMPLIANCE?A Checklist: Submit HIS and CAHPS Hospice Survey data on time in the calendaryear. Monitor your data submission and performance in meeting the 90%threshold for HIS. Monitor vendor submissions for CAHPS Hospice Survey. Utilize available reports in the Certification and Survey ProviderEnhanced Reports (CASPER) reporting application for both HIS andCAHPS Hospice Survey. HIS and CAHPS have separate CASPERReports.24

CASPERREPORTS TRACKINGCOMPLIANCE

CASPER REPORTS - TRACKINGCOMPLIANCE26

CASPER REPORTS AND THEIRIMPORTANCE TO TRACK HQRPCOMPLIANCE Agencies should access their CASPER reports on a regular basis. You canobtain more information about the reports in The CASPER ReportingUser's Guide for Hospice Providers. Here is another useful webinar to further your knowledge of CASPERReports: Hospice Quality Reporting Program: Review and Correct ReportOverview Webinar. Be sure to also check your CAHPS Data Warehouse Report. Forinformation about this warehouse and sign-up for access, please go to:https://hospicecahpssurvey.org/27

HOW WILL YOU KNOW IF YOURHOSPICE IS HQRP-COMPLIANT? Review your HIS and CAHPS data regularly using the Reports available inCASPER. You are responsible for knowing whether you are in compliancewith HQRP requirements. CMS considers the timeliness of both HIS and CAHPS survey datasubmitted and accepted by hospices to CMS to determine the APUcompliance. CMS sends letters of noncompliance in the summer of the year followingdata collection. If you receive a letter and disagree with the determination,you can file a reconsideration request.28

RECONSIDERATIONPROCESS

RECONSIDERATION PROCESS30

WHAT IS THE HQRP COMPLIANCECYCLE?There is a 2 year cycle of data collection, compliance determinations, and payment impact.Hospice’s DataCollection & Submissions(HIS and CAHPS )CY 2020CMS onPayment ImpactAPU in Effect for FY 2021(October 1, 2021 - September 30, 2022)Non-Compliant HospiceCompletes ReconsiderationRequests Within 30 DaysCY 202131CMS DeliversReconsiderationResults

RECONSIDERATIONS The Reconsideration Requests web page providesinformation and updatesrelatedRequeststo theThe Reconsiderationwebannualpage providesreconsideration processHQRPinformationforandtheupdatesrelated toAPUthe annualdeterminations. reconsideration process for the HQRP APU On this page you determinations.will find guidelinesandyouprocessesfor andOn this pagewill find guidelinesrequesting and submitting reconsideration requests for aprocesses for requestingsubmittingreconsiderationdetermination of ts for a determination of noncompliance withhospicequalityreporting. You can also contacttheHelpDesk for questionsrelated to reconsiderations by emailing theYou can also contact the Help desk for questions related reconsiderations by emailing theReconsideration Help Desk:Reconsideration Help Desk: econsiderations@cms.hhs.gov.32

EXTENSIONS AND EXEMPTIONSThe Extensions and Exemptions webpage can help you navigate special circumstances.This policy consists of two parts: Provider-initiated requests for exemption or extension for extraordinarycircumstances: if a hospice provider experiences an extraordinary circumstance, they caninitiate a request for extension or exemption. The request must be initiated within 90 daysof the extraordinary circumstance event and it must be sent to CMS via email following theinstructions explained on the webpage. CMS-initiated waivers for exemption or extension for extraordinary circumstances:when a natural or man-made disaster impacts a large geographic area or large number ofhospice providers, CMS can automatically grant an exemption or extension groups ofaffected providers. In CMS-initiated waivers, providers do not need to take any action to begranted an exemption or extension. CMS-initiated waivers are communicated to providersvia the communication channels noted on the webpage.33

FISCAL YEARPAYMENTIMPACT

FISCAL YEAR PAYMENT IMPACT35

WHAT IS THE HQRP COMPLIANCECYCLE?There is a 2 year cycle of data collection, compliance determinations, and payment impact.Hospice’s DataCollection & Submissions(HIS and CAHPS )CY 2020CMS onPayment ImpactAPU in Effect for FY 2021(October 1, 2021 - September 30, 2022)Non-Compliant HospiceCompletes ReconsiderationRequests Within 30 DaysCY 202136CMS DeliversReconsiderationResults

HELP DESK INFORMATION General HQRP or HIS-specific InquiriesHospice Quality Help Desk: HospiceQualityQuestions@cms.hhs.gov CAHPS -specific Inquirieshospicecahpssurvey@hsag.com or 1-844-472-4621CMS staff about implementation issues: hospice survey@cms.hhs.gov Reconsideration Help Desk to Appeal any Initial Notice of Non-compliance withHQRP Requirements: HospiceQRPReconsiderations@cms.hhs.gov Technical Assistance with QTSO, QIES, HART, or CASPERQTSO Help Desk: Email: help@qtso.com / Phone: 1-877-201-4721 (M-F, 7AM-7PM CT)37