by Marian Essey, RN, BSN, COS-C
The Social Security Act (Section 1814(i)(5)(C)) requires hospices to submit data to CMS and requires a payment reduction to hospices that fail to report data as specified by the Secretary of U.S. Health and Human Services. The Consolidated Appropriations Act of 2021 amended the Social Security Act and updated the payment reduction for failing to meet hospice quality reporting requirements was from a 2% reduction in Medicare fee-for-service (FFS) payments to a 4% reduction beginning with fiscal year (FY2024).
The Hospice Annual Payment Update (APU) is the annual adjustment CMS applies to what hospices get paid by Medicare for patient care. Hospices that don’t comply with the reporting requirements have their APU reduced by 4%.
To be compliant with this requirement, hospices must submit both Hospice Item Set (HIS) data and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey data. HOPE will replace HIS in this requirement.
To understand APU compliance requires an understanding of the terms and timeframes used in the calculations. In this article, we’ll only be discussing HIS/HOPE requirements and associated terms and timeframes and will not be reviewing Hospice CAHPS Survey requirements.
APU is applied to FY payments based on compliance in the corresponding Reporting Year.
APU is applied to the Payment Year two years after the Reporting Year. For example, the APU for the CY 2024 Reporting Year is applied to the FY 2026 Payment Year. See diagram below.
For HIS, CMS uses HIS Admission and HIS Discharge records to calculate the data submission requirements. To be compliant, hospices must submit, and CMS must accept, 90% of HIS Admission and HIS Discharge records within 30 days of the event date (also known as the target date or completion date of the admission or discharge).
In the CY 2025 Hospice Final Rule, CMS has noted that, “[CMS] will apply the same submission requirements for HOPE admission, discharge, and up to two hospice update visit (HUV) records. After HIS is phased out, hospices will continue to be required to submit 90% of all required HOPE records to support the quality measures within 30 days of the event or completion date (patient’s admission, discharge, and based on the patient’s length of stay up to two HUV timepoints).” CMS went on to say, “Most hospices that fail to meet HQRP requirements do so because they miss the 90 percent threshold.”
CMS informed hospices in the CY 2025 Hospice Final Rule that, “…during the first reporting year that implements HOPE, APUs may be based on fewer than four quarters of data. [CMS] will provide additional subregulatory guidance regarding APUs for the HOPE implementation year.”
It’s important to note that CMS has not yet confirmed that APU will be based on less than 4 quarters of data for the CY 2025 reporting year, therefore it is imperative for hospices to have their HOPE data collection and submission process as accurate and efficient as possible for the October 1, 2025 launch of HOPE.
To ensure your hospice understands the HOPE requirements and is accurately and efficiently collecting and submitting HOPE data, check out the OASIS Answers HOPE Training Video, HOPE in Action.
Follow OASIS Answers to keep on top of new CMS information related to the Hospice Quality Reporting Program, the Hospice Outcomes and Patient Evaluation (HOPE), and more!
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