CONSIDERATIONS FOR AFFECTED PROVIDERS AND FACILITIES THAT CHOOSE TO REPORT DATA UNDER AN EXTRAORDINARY  CIRCUMSTANCE EXCEPTION (ECE)

Providers and facilities should be aware of the potential impact to reporting requirements and

payment programs when deciding whether or not to report data included in the exceptions. A provider or facility may still choose to submit complete and accurate data they have collected which are covered under these exceptions. In such cases, the exception will be considered unneeded and the data processed and publicly reported in accordance with normal operations.

In particular, hospitals located within the designated affected areas listed under this disaster declaration should be aware of the potential subsequent impact to the Hospital VBP Program and HAC Reduction Program minimum case threshold counts for inclusion in these programs and which measures have enough data for scoring. For example, hospitals might be scored solely on the HAC Reduction Program’s claims-based CMS Patient Safety and Adverse Events Composite (CMS PSI- 90) measure due to non-submissions resulting in not meeting the minimum number of Centers for Disease Control and Prevention’s HAI measures with sufficient cases. For the HAC Reduction Program, if data for the excepted period are submitted, they will be used for scoring in the program.

CASES OF NON-EXCEPTION

Program Participants in Non-Designated Areas

Providers and facilities located outside the FEMA-designated areas are not covered by these exceptions, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs they participate in using the applicable ECE request process for the respective program(s). CMS will assess and decide upon each ECE request on a case-by-case basis.

End-Stage Renal Disease Quality Incentive Program (ESRD QIP)

The ESRD QIP does not participate in these exceptions. In the event of an extraordinary circumstance preventing a dialysis facility from submitting data or accessing medical records, the facility may submit an ECE request and review the status of requests in the ESRD QIP User Interface (UI) in ESRD Quality Reporting System (EQRS). For detailed instructions on utilizing the ECE application in EQRS, please refer to the ESRD QIP ECE UI Guide.

Facilities are not required to submit ECE requests in EQRS. Requests may also be submitted by accessing the online form. To request an ECE using the online form, a facility needs to download, complete, and submit the ECE Form from QualityNet. In addition to completing the form, the facility should submit any supporting documentation within 90 days of the extraordinary circumstance. These documents must be submitted to the ESRD QIP Team by sending an email to ESRDQPS-Admin@arborresearch.org.

Medicare Promoting Interoperability Program

Under the Medicare Promoting Interoperability Program, a Hardship Exception Application may be available for eligible hospitals and critical access hospitals affected by the aforementioned disaster, as long as the requesting eligible hospital or critical access hospital has not met the 5 hardship maximum (as set forth in Social Security Act section 1886(b)(3)(B)(ix)(II)). Please note that the Medicare Promoting Interoperability Program has a separate hardship exception process from the