CMS Reporting Requirements: What Providers Must Know

The United States has one of the most highly regulated healthcare sectors in the world. The regulatory framework that governs how hospitals, physicians, and other healthcare organizations operate is largely determined by the Centers for Medicare & Medicaid Services (CMS). The CMS programs directly affect how much reimbursement is received from the federal government for providing care to patients, the status of an organization’s compliance with federal regulations, and the benchmarks used to assess quality of care that is provided to patients.

CMS data shows that there are more than 66 million individuals enrolled in Medicare and more than 90 million individuals enrolled in Medicaid programs in the US. These two programs comprise one of the largest healthcare funding systems in the world, providing trillions of dollars each year.

In addition to providing economic support to healthcare providers through the reimbursement process, the CMS requires healthcare organizations to report detailed data regarding quality measures, patient outcomes, care coordination, and cost efficiency. CMS reporting programs (MIPS, APMs, and Hospital Quality Reporting) are utilized to ensure that healthcare providers are providing high-value care as opposed to volume-based care.

The complexity of the CMS reporting process can make compliance with federal regulations a challenge for healthcare providers. Different CMS programs as well as their requirements that must be met can be overwhelming for a provider without a well-organized system.

What Are CMS Reporting Requirements?

The purpose of reporting requirements under the CMS is to provide information about how well the healthcare provider offers certain services under the Medicare and Medicaid programs and to provide documentation related to these services through the related programs.

Through reporting requirements, CMS:

• Evaluates the quality of care provided by a healthcare provider
• Monitors health outcomes of patients
• Controls costs associated with the delivery of healthcare
• Enhances and improves the coordination of healthcare services
• Rewards healthcare providers who provide value-based healthcare services

The data reported provides CMS with information about patient health status, clinical quality indicators, data regarding the health of a population, coordination of care between healthcare providers and providers’ costs to provide healthcare services.

CMS will use the reporting requirements to assess the performance of a healthcare provider and to determine the healthcare provider’s eligibility for reimbursement under the Medicare and Medicaid programs; therefore, it is critical that healthcare providers comply with CMS’s reporting requirements.

The failure of healthcare providers to comply with CMS reporting requirements can lead to fines, loss of reimbursement for Medicare services, compliance audit, and regulatory oversight of the healthcare provider.

Why CMS Reporting is Important For Healthcare Providers?

CMS reporting is not just a regulatory obligation; rather it is a significant factor affecting the financial stability and reputation of an organization in the healthcare sector. The reporting requirements are important due to financial impact associated with the services that are reimbursed by the Medicare program.

Providers that report quality metrics and show high performance are eligible for a positive payment adjustment or an incentive payment. Those unable to meet certain standards for reporting may incur penalties that reduce their ability to be reimbursed by Medicare. Since the penalties can be as high as 9% of total Medicare payments in some programs, it is very important for providers to report accurately.

• Support for Value-Based Care Models

The U.S. healthcare delivery system is moving from a “fee-for-service” delivery model to a “value-based” care delivery model, also referred to as accountable care. Under this model, providers receive reimbursement for:

• • Providing better patient outcomes
  • Providing lower-cost healthcare
  • Reducing preventable readmissions to hospitals
  • Effectively coordinating care among providers

CMS provides performance measures that help organizations evaluate their performance on the above indicators and help determine which organizations are providing value-based care.

• Improving Care Quality and Patient Outcomes

Quality Reporting Programs also assist healthcare organizations in identifying gaps in their delivery of care. Quality indicators measured by CMS Quality Reporting Programs include:

• • Rate of readmission of patients to hospitals
  • Management of chronic disease
  • Use of preventive medical services and screenings
  • Patient satisfaction rate

By analyzing these indicators, healthcare organizations can improve their strategies for delivering care and can therefore improve patient outcomes.

Major CMS Reporting Programs in the United States

Healthcare providers throughout the United States have numerous reporting programs with CMS that they need to adhere to according to the type of organization they are and their participation level. It is important for providers to understand these programs in order to ensure compliance.

1. Merit-Based Incentive Payment System (MIPS)

The Merit-Based Incentive Payment System (MIPS) is one of the most well-known reporting programs by CMS. MIPS assess eligible clinicians on four main categories of performance:

• • Quality
  • Cost
  • Improving activities
  • Promoting interoperability

Providers report data on an annual basis in order to receive a performance score from CMS, which is used to determine if they are eligible for a payment bonus or penalty. Healthcare organizations must submit timely and accurate data because MIPS scores directly relate to how the clinicians are reimbursed.

2. Advanced Alternative Payment Models (APMs)

Advanced APMs use a unique model that changes how care is delivered and paid through the use of existing CMS programs; thus these advanced APM’s are different than how traditional CMS programs have functioned. Advanced APMs require care coordination across facilities for identified populations at-risk. Providers are responsible for reporting on the following:

• • Efficiency of cost management
  • Outcomes for patients in a defined population
  • Quality of care delivered to patients

Advanced APM providers who are successful based upon their reported data may be eligible for additional payments and will not have to report to MIPS.

3. Inpatient Quality Reporting (IQR) Program

All hospitals that participate in the Medicare program must comply with the requirements set out by The Inpatient Quality Reporting (IQR) Program. Currently there are many metrics that hospitals must submit data related to their clinical operating and patient outcome performance. Examples of some common metrics for Inpatient Quality Reporting include:

• • Death Rates
  • Hospital Acquired Infections
  • Safety of Patients
  • Emergency Room Efficiency
  • Post-Surgical Complications

If a hospital does not report on the above metrics that have been prescribed by the IQR program they may be penalized by receiving reduced updates in payments from Medicare.

4. Hospital Outpatient Quality Reporting (OQR) Program

Outpatient Care Facilities must adhere to the OQR program. The purpose of OQR is to enhance outpatient quality of care by establishing measurement standards through various measures including:

• • Imaging efficiency
  • ED throughput
  • Patient experience
  • Preventative services

As with all CMS Reporting initiatives, providers that fail to meet reporting standards may incur penalties.

Key Data Elements Required By Providers in CMS Reporting

CMS Reporting requires providers submit multiple types of data related to their delivery of healthcare. These data elements generally include:

• Clinical Quality Measures

Clinical quality measures track the total quality of the provider’s implementation of evidence-based clinical guidelines. Examples include:

• • Control of blood pressure in patients with hypertension
  • Management of diabetes
  • Preventative care screenings
  • Adherence to prescriptions

Each of these measures allow CMS to evaluate whether or not the provider has followed generally accepted the clinical guidelines.

• Cost & Resource Use Metrics

CMS tracks providers’ use of healthcare resources to determine if the provider has the ability to provide a high quality of care in a financially responsive manner. To identify the costs associated with providing high quality of patient care, CMS uses several metrics, including:

• • Rate of hospital readmissions
  • Rate of emergency room visits
  • Rate of preventable hospitalizations
  • Total cost of providing care to each patient

Cost reporting allows CMS to identify opportunities for providers to reduce unnecessary expenditures for healthcare.

• Patient Engagement and Experience

Patient engagement and satisfaction is also a vital aspect of reporting to CMS. Healthcare organizations report metrics on:

• • Communication with patients
  • Coordination of care
  • Follow up on care
  • Education about patient’s health/illnesses

These metrics enable healthcare providers to better understand how well they engaged patients in care delivery.

• Technology & Interoperability Data

CMS use of digital health technology provides evidence that healthcare providers are effectively using technology to deliver patient care. Reporting can include information on:

• • Overall use of EHR
  • Health information exchange
  • Use of secure communications
  • Accessing patient portals

These data points support CMS’s efforts to build a more connected healthcare system.

What Healthcare Providers Can Do To Improve Their CMS Reporting?

Adopting best practices will help healthcare providers to improve their performance for CMS reporting. Some of the essential ones include:

1. Implement Integrated Data Systems

Using an integrated data system to store and report healthcare information saves time, effort, and ensures much more accurate reporting. An integrated data system consists of:

• • EHR information
  • Patient monitoring System
  • Coordination of care Workflow
  • Quality Reporting Tools

When the provider uses an integrated data system, he/she can spend less time on manual effort preparing reports and gathering information for reporting.

2. Track Performance Metrics Throughout The Year

Providers have a higher chance of making errors on a report the closer they get to their report due date. Tracking performance metrics throughout the year, as opposed to waiting for the due date, allows for any error to be found early, allowing the provider an opportunity to correct it immediately.

3. Train Staff on Documentation Requirements

To achieve accurate CMS reporting, it is vital that there is correct documentation by the staff within healthcare organizations.  The staff should receive training on:

• • Acceptable methods for clinical documentation
  • Definition of each quality measure
  • Restrictions associated with compliance

There is a huge decrease in reporting error when the staff has undergone adequate training.

4. Utilization of Automated Reporting Tools

Tools that allow automatic generation of quality reports, tracking of performance measurement and ensuring CMS submissions, frees up administrative workload for providers while simultaneously enhancing accuracy in the compliance report generated.

Digital Health Platform’s Role in Meeting CMS Reporting Requirement

The way in which providers manage their responsibilities under the CMS program is being altered due to the introduction of new technologies within healthcare.  Through the use of digital healthcare platforms, providers can:

• Automatically obtain relevant patient health information
• Track their performance measures in real time
• Integrate clinical and reporting workflows
• Limit their risk for failing to comply with CMS regulations.

Through the use of real-time information retrieval from electronic health records, healthcare organizations will have more accurate documentation and provide superior patient outcomes as compared to those who do not utilize these technologies, such as Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Therapeutic Monitoring (RTM).

How CMS Reporting is Going to Change in the Future

Reporting requirements for CMS will change in the coming years as the health care system begins to transition into a healthcare system based on value rather than volume. There are several trends that are expected to affect the development of future reporting systems.

• An increased focus on patient outcomes rather than procedures
• An increased use of remote monitoring technologies in reporting
• An increased need for interoperability between providers, hospitals and care teams

CMS will continue to push healthcare organizations toward interoperability and data sharing with their stakeholders (i.e., their providers, their hospitals, and their care teams) to meet future reporting requirements.

Frequently Asked Questions (FAQs) About CMS Reporting

HealthArc Streamlines CMS Reporting for Healthcare Providers

CMS develops and maintains reporting requirements that influence how effectively they manage and deliver care. By encouraging hospitals to work toward improved patient outcomes, better coordination of care, and higher efficiency, CMS established a new standard for measuring the quality of care delivered by healthcare organizations.

HealthArc is a pioneer in remote healthcare platforms and assist providers with innovative tools that support implementation of advanced care programs like Remote Patient Monitoring, Chronic Care Management and Remote Therapeutic Monitoring while meeting CMS compliance and reporting requirements.

By integrating patient data, remote monitoring devices, care coordination workflows and analytics into one platform, healthcare organizations can provide real-time health monitoring for patients, enhance positive care results and improve their ability to meet CMS reporting requirements in an efficient manner.

Through the use of clinical intelligence, automation and seamless interoperability, we are enabling providers to achieve their goals while improving patient engagement and operational performance. Need to know more about our platform and services? Feel free to schedule a demo now or book a consultation.