Upcoming Deadlines: Medicare Quality Program Reporting and Reweighting Extensions

December 10, 2020

MEMORANDUM

There is a process to request an extension for submitting Medicare Quality Data to the Centers for Medicare & Medicaid Services (CMS).  CMS has an Extraordinary Circumstances Exceptions (ECE) policy to generally assist hospitals when there are extraordinary circumstances beyond their control.  Such circumstances may affect the performance of the hospital within various Medicare quality programs, impacting future Medicare payments.  Hospitals may also experience hardship meeting data submission deadlines due to necessary redeployment of resources away from administrative tasks and toward providing patient care and ensuring the health and safety of staff.

Similarly, there are two exception applications available to clinicians, groups, virtual groups and Alternative Payment Model (APM) Entities participating in the Merit-Based Incentive Payment System (MIPS): the Extreme and Uncontrollable Circumstances Exception and the MIPS Promoting Interoperability Performance Category Hardship Exception.

While CMS automatically exempted some providers, including hospitals, from certain quality data reporting requirements in the first two quarters of 2020 due to the COVID-19 public health emergency (PHE), they have not extended such waivers to the third and fourth quarters of 2020.  However, hospitals and MIPS-eligible entities may apply for individual exceptions if they believe that their performance continues to be adversely affected by the PHE.

Hospital Medicare Quality Programs
Hospitals may apply for exceptions to reporting requirements under the Hospital Inpatient Quality Reporting (IQR) Program.  This includes the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program (RRP).  Hospitals must apply for an individual ECE within 90 days of the date of the extraordinary circumstance, such as the current surge in coronavirus-related hospitalizations.  The application for an ECE is on the CMS QualityNet IQR website.  Additional information on individual ECE applications and the automatic exemption during the first half of 2020 is in this FAQ document on the QualityNet IQR website.

Hospital providers with questions about the ECE application should contact the Hospital Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at 1-844-472-4477.

MIPS
MIPS eligible entities adversely impacted by COVID-19 may submit one of two exception applications for performance year 2020.  The Extreme and Uncontrollable Circumstances Exception allows eligible entities to request reweighting for any or all performance categories if extreme and uncontrollable circumstances outside your control adversely impact your performance.  The application deadline for this exception is Feb. 1, 2021.  The application process and additional information are on CMS’ Quality Payment Program website.

Eligible clinicians may also apply for a MIPS Promoting Interoperability Performance Category Hardship Exception, which allows you to request reweighting specifically for the Promoting Interoperability performance category.  Eligible entities must cite one of the following reasons for the exception:

• You are a small practice;
• You have decertified Electronic Health Record (EHR) technology;
• You have insufficient Internet connectivity;
• You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues; or
• You lack control over the availability of certified electronic health record technology (CEHRT).

The application deadline for this exception for the 2020 program year is Dec. 31, 2020.  The application process and additional information are on CMS’ Quality Payment Program website.

Providers with questions about the MIPS Quality Payment Program should contact the Quality Payment Program at 1-866-288-8292 or QPP@cms.hhs.gov.

IHA encourages all providers concerned with either their performance or ability to meet requirements under these various quality programs to submit an exception application.  Please send general Medicare quality program related questions to IHA.