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:
- Initial notice from CMS to hospitals that do not meet reporting requirements completely on a daily basis.
- Reminder notice three weeks after initial notice for continued failure to meet the reporting requirements.
- 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.
- Second enforcement notification letter within one week following the first enforcement notice giving one week to demonstrate compliance.
- 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.