Regulatory Reminders

Welcome back to Regulatory Reminders. It’s been a while. The last few days have been active so head’s up on two important developments!


The COVID Public Health Emergency has been extended. See the announcement here. With this extension all of the waivers that have not been rescinded by previous orders, including the 3-day stay and benefit period waivers, will essentially remain in effect unless and until further notice. Here is what the current extension language says:

Renewal of Determination That A Public Health Emergency Exists

As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Xavier Becerra, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective July 20, 2021, the January 31, 2020, determination by former Secretary Alex M. Azar II, that he previously renewed on April 21, 2020, July 23, 2020, October 2, 2020, and January 7, 2021, and that I renewed on April 15, 2021, that a public health emergency exists and has existed since January 27, 2020, nationwide.

Xavier Becerra -United States Secretary of Health and Human Services


Last week CMS issues an announcement regarding SNF Quality Reporting Program (QRP) reporting non-compliance affecting the FY2022 Annual Payment Update (APU) or market basket update, i.e. FY 2021 proposal is 1.2%. Compliance with SNF QRP reporting requires that nursing facilities report 100% of the data necessary to calculate the SNF QRP quality measures on at least 80% of MDS assessments submitted. Anything below that threshold is considered non-compliance. Letters issued to non-compliant facilities have been posted in their CASPER folders and some MACs have also issued these as well. These letters state the following.

“This letter is to officially notify you that SNF ABC did not meet one or more of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) requirements for Calendar Year (CY) 2020 data submission that impacts Fiscal Year (FY) 2022 Annual Payment Update (APU). Failure to meet the requirements of the SNF QRP will result in a two (2) percentage point reduction in the FY 2022 APU.”

The letter goes on to indicate that, “Due to the impacts of COVID-19 during Q1 and Q2, the APU payment impact for FY2022 is based upon data collected in Q3 and Q4 of calendar year 2020 only.” The letter also states, “If you believe you have been identified for this payment reduction in error, you have the right to request a re-consideration of this decision. Reconsiderationinstructions are also included in the letter. It is important to check your facility folder in CASPER to determine if your facility has been notified about SNF QRP reporting non-compliance and to follow through with a reconsideration if you believe that you were compliant.

Normally, relatively few facilities are affected by this. However,  because there are only two measurement quarters under consideration this year, when normally there are four, the shortened measurement time period makes it statistically more likely that there will be more providers affected since a smaller number of non-compliant assessments will have a much larger impact. For example: if my facility submits 200 PPS MDS assessments in a year (50/quarter), and I had 25 non-compliant assessments, that would be 12.5% non-compliance or 87.5 compliance for four quarters. However, if 21 of those non-compliant assessments occurred in the two quarters included in this year’s measurement period, then I would now be at 21% non-compliance or 79% compliant and would not have met the 80% threshold and I would receive a letter.

Many facilities will be surprised by this. I have spoken with three facilities already who were actually compliant for 4 quarters but reached the non-compliant threshold (<80%) relative to the two quarters being measured. In my estimation this is not fair and these facilities will be asking for a reconsideration. Q3 and Q4 of 2020 were heavy COVID months for most facilities and months in which staffing levels were challenged etc.

Facilities should regularly check their compliance with SNF QRP reporting requirements to avoid this scenario. This can be accomplished by doing two simple tasks on a routine basis.

First, always review your MDS submission validation reports. If you notice error message 3897 there is a  problem. Error message 3897 says this. “WARNING: Message: Payment Reduction Warning: If A0310B equals 01 or 08, then a dash (-) submitted in this quality measure item may result in a payment reduction for your facility of two percentage points for the affected payment determination.” It shows up when an item on the MDS that affects one of the QRP quality measures contains a dash. By noticing this is real time facilities an make corrections then and not wait until the only recourse is reconsideration.

Second, check your SNF QRP Provider Threshold Report located in the reports selection tab in CASPER. If you run that report quarterly you will see your reporting compliance percent rolling as of that quarter. Unfortunately you cannot set a time parameter on these reports so if you don’t run them quarterly you may not notice an issue.

Check your CASPER folder and don’t be surprised. While the adjustment to the FY 2022 APU may be a minor financial imposition, completing the MDS completely is a much broader issue and one that has a very broad reach beyond SNF QRP. Time is short and reconsideration requests will be accepted via email no later than 11:59:59 pm local time zone, August 13, 2021 at the following address: