September 19, 2023
NOTICE: IQR-Eligible Hospitals to Submit 2Q 2023 Survey Data by October 4, 2023
The submission deadline for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient perspectives on care survey data for second quarter (2Q) 2023 discharges (April 1-June 30, 2023) is October 4, 2023.
The Centers for Medicare & Medicaid Services (CMS) strongly encourages all hospitals, whether they self-administer the HCAHPS Survey* or use a survey vendor, to submit data well before the deadline to allow time to address any submission issues.
- Inpatient Prospective Payment System (IPPS) hospitals participating in the Inpatient Quality Reporting (IQR) Program must collect and submit HCAHPS data to qualify to receive their full Annual Payment Update. Please see the Q2 2023 Hospital IQR Checklist for further information.
- Non-IPPS hospitals must meet the same submission deadline for their data to be published on public reporting website.
Review and Correction Period
- The Review and Correction Period is October 5-11, 2023.
- Immediately following the October 4, 2023 data-submission deadline, participating hospitals and survey vendors have a seven-day opportunity, October 5-11, 2023, to access and review the HCAHPS Data Review and Correction Report.
- The report contains a summary of the data accepted into the HCAHPS Data Warehouse for the quarter. Errors in data accepted into the warehouse by the October 4, 2023 deadline can be corrected. During this seven-day period, corrected data can be submitted to the warehouse to replace incorrect data. New data are not accepted into the warehouse during the Review and Correction Period.
Extraordinary circumstances exceptions (ece)
In the event that your hospital is unable to submit data or meet requirements due to an extraordinary circumstance, you may request an individual exception.
- For the submission of the HCAHPS data, for the Hospital IQR Program, the ECE must be submitted within 90 calendar days from when you determined that the extraordinary event occurred. The event may occur during the measurement period through the submission or reporting deadline.
- For events adversely impacting your HCAHPS performance, for the Hospital Value-Based Purchasing (HVBP) Program, the ECE must be submitted within 90 days of the date of the extraordinary circumstance. At the latest, ECEs should be submitted no later than 90 days from the last date of the quarter requested.
- For example, the last day of Q2 2023 is June 30, 2023. The ECE should be submitted no later than 90 days after the end of Q2, which will be September 28, 2023.
Please refer to the HVBP and IQR resources on QualityNet for further information.
Hospital Contact Information: To ensure your hospital receives critical communications about meeting the requirements of the IQR Program (and other CMS quality reporting programs), including submission-deadline reminders and program updates, it is important that we have the complete contact information for the key roles at your hospital. Updates to your contact information can be submitted, if needed, using the Hospital Contact Form. This document is available on the Quality Reporting Center website (www.qualityreportingcenter.com > Inpatient > Hospital IQR Program > Resources and Tools > Forms).
HCAHPS Contact Information
- For general questions regarding the HCAHPS Survey, contact CMS at Hospitalcahps@cms.hhs.gov.
- For questions regarding HCAHPS Survey administration, contact the HCAHPS Project Team at (888) 884-4007 or at email@example.com.
- For questions regarding HCAHPS data submission information, contact the CCSQ Service Center at (866) 288-8912 or at firstname.lastname@example.org.
- For questions regarding information on the HCAHPS initiative, file specifications, and data-submission protocols, use the contact information on the HCAHPS website at hcahpsonline.org.
- For questions regarding the IQR Program, use the Inpatient Questions & Answers tool at https://cmsqualitysupport.servicenowservices.com/qnet_qa?id=ask_a_question or call the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team at (844) 472-4477.
*The HCAHPS Survey is also known as the CAHPS® Hospital Survey. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.
September 1, 2023
Reminder! MBQIP Data Reporting Reminders – September 2023
Important Notice: Dates for measure submission and Specification Manual/CART versions are based on currently available information and may be subject to change.
October 31, 2023
Emergency Department Transfer Communication (EDTC)
- Patients seen Q3 2023 (July, August, September)
- Submission process directed by state Flex Program
November 1, 2023
CMS Population and Sampling (optional)*
- Patients seen Q2 2023 (April, May, June)
- Inpatient** and outpatient
- Entered via the Hospital Quality Reporting (HQR) HARP account
November 1, 2023
CMS Outpatient Measures:
- Patients seen Q2 2023 (April, May, June)
- CMS Hospital Outpatient Reporting Specifications Manual version 0a
- Submitted to HQR via CART or by vendor.
- CART version – 22.0
November 15, 2023
CMS Inpatient Measures**:
- Patients seen Q2 2023 (April, May, June)
- CMS Hospital Inpatient Reporting Specifications Manual version 13
- Submitted to HQR via CART or by vendor
- CART version – 30.1
*Population and sampling refers to the recording of the number of cases that meet the initial measure set population requirement and the number of cases the hospital is submitting to Hospital Quality Reporting thru a HARP account for the quarter.
** Currently there are no inpatient chart abstracted core MBQIP measures required.
August 25, 2023
Report Outlines Quality Improvement Strategies for CAHs
A new report offers practical, rural-relevant strategies that critical access hospital (CAH) leaders and staff can adopt to more fully incorporate quality improvement efforts into their organization’s culture and develop a shared sense of responsibility for quality patient care. Based on discussions among rural health quality leaders from across the country who attended the Critical Access Hospital Infrastructure Summit earlier this year, the report is the work of the National Rural Health Resource Center, in partnership with the Flex Monitoring Team and Stratis Health.
August 25, 2023
Updated Maternal and Child Health (MCH) Leadership Competencies
The Maternal and Child Health Bureau (MCHB) Division of Maternal and Child Health (MCH) Workforce Development released updates to the Maternal and Child Health Leadership Competencies. The MCH Leadership Competencies support current and future MCH leaders by defining the knowledge and skills necessary to lead in this field.
The MCH Leadership Competencies describe the necessary knowledge, skills (foundational and advanced), and values within a framework designed to support and promote MCH leadership. Therefore, the Competencies can be used in a variety of ways, including:
- As a framework for training objectives for MCH training programs. It is the responsibility of MCH training programs to ensure that graduates have the foundation necessary to work within a variety of professional settings to contribute to the health and well-being of mothers, children, and families – and to inspire others to do likewise.
- To measure and evaluate MCH leadership training. The MCH Leadership Competencies can be used to guide measurement and evaluation of the impact of leadership training.
- To cultivate, sustain, grow, and measure leadership within the current MCH workforce. The MCH Leadership Competencies can be used as a tool to strengthen the leadership abilities of current MCH professionals in national, state, and local health agencies, academia, and other MCH organizations. In particular, the framework can assist in orienting those new to the field to the goals and methods of MCH, assess and promote leadership capacity, and guide continuing education efforts.
Also important is the understanding that leadership (1) can be developed through learning and experience; (2) can be exerted at various levels within an organization and at the national, state, or local levels; and (3) opportunities change over time.
The document is intended to be a resource for MCH interdisciplinary training programs, national, state, and local health agencies, and other MCH organizations.
Click Here to Learn More
August 21, 2023
Large Health Care System Suffers Rhysida Attack
Rhysida is an emerging threat group, targeting many critical infrastructure sectors including the Healthcare and Public Health (HPH) sector. It is a ransomware-as-a-service group which deceitfully describes itself as a “cybersecurity team” projecting themselves as helping victims highlight potential security issues and secure their networks. While not much is known about the group’s origins or country affiliations, Rhysida ransomware is deployed in multiple ways.
On August 3, 2023 Rhysida attacked a health care system which operates 16 hospitals and more than 165 clinics and outpatient centers in four states.
According to reports, the attack resulted in “emergency departments to close, ambulances to be diverted, and other medical services to cease operations” in what appeared to be a ransomware attack.
The attack required the hospitals to take their systems offline to protect their patient data and to revert to using paper records. In some states, the health system’s blood draw stations and medical imaging locations were also impacted. Areas saw emergency departments, as well as some primary and specialty locations closed until further notice. As a result, impacted entities were contacting patients individually due to the various effects to patient care.
Read the 2-page August 16, 2023 Brief released by the HHS 405(d) Task Group which also recommends that your IT department implement the following best practices found in their FREE resources, such as the Health Industry Cybersecurity Practices (HICP) Technical Volumes 1&2 and Knowledge on Demand to protect your valuable health information from such threats.
Low-cost resources offered by the American Institute of Healthcare Compliance (AIHC) – a non-profit organization:
August 9, 2023
Telehealth.HHS.gov provides trusted telehealth resources that cover a wide range of topics including workflow and staff training, reimbursement, and behavioral health. Easily access various topics and areas of interest for providers and patients.
- Behavioral Health
- Chronic conditions
- Health equity
- Internet Access
- Maternal health and pediatrics
- Reimbursement and policy
Learn more about telehealth resources
August 9, 2023
Increase Your Revenue – Check out the Access Plus Underpayment Recovery System
The Access Discount Healthcare (ADHC) Underpayment Recovery System Analysis Audit is a proprietary technology system that identifies and recovers underpayments, manages denials and overpayment fines and responses, automates appeals and requests, and is a contract modeler essential in negotiating more favorable contracts. This risk free service is a bonus addition to your Revenue Cycle Management (RCM) efforts.
Cost: $0 upfront fees
- ADHC funds all the costs and risks, including contract load fees, appeals processes, audit and training which is applied to the recovery fee.
- All fees are 100% paid by a % of recovered underpayment fees from the initial audit of past claims
Where do underpayments go when recovered?
- All underpayments are paid directly to the client, by the payer
- ADHC bills the client for a percentage of recovered underpayments, after the client is paid
Expected recovery of past underpayments:
- Historically, the underpayment system uncovers 5-30% of your total commercial, Medicare and Medicaid payments which have been paid incorrectly, on every analysis – the average recoupment is 20% of your total revenue.
- Collection statistics for commercial payer underpayments are 85-90% of identified claims
How long does the analysis take to complete?
- Minimum facility time is 30 minutes or less to upload 835 electronic billing records
- Once all contracts and data files are received, it typically takes 14 days to complete the analysis and start the appeals process
What this service will do:
- Analyze every remittance within a 12-24 month period to determine contractual compliance of each reimbursement
- Works with payers to recover underpayments
- Under payment recovery
- Risk free addition to Revenue Cycle Management (RCM)
- Work with payers to recover underpayments
What makes this service different?
- Works only with remittance files which clients expect no further revenue, making their services a compliment to all your other RCM efforts
- Provides new revenue
- Analyzes billions of dollars in reimbursements and remittances, finding noncompliance and underpayments for 100% of their clients
- Typical result is 10% – 20% of gross payer receipts in recovery
- Work solely on a contingency basis
- No upfront fees, costs, ongoing tasks required from clients
- They take 100% of the risk and effort to recover revenues for their clients
- Access Healthcare are only compensated at the successful recovery of underpayments for your facility
For more information, or to schedule a call, contact:
Zach Evans, Managing Principal
Clearview Savings Consultants, LLC
The above program information is being forwarded by the Office of Rural Health and Primary Care (ORHPC) as a service of this office. ORHPC does not endorse or recommend any vendor or service. Please review for the appropriate use within your organization.
August 9, 2023
HRSA Virtual Job Fair – August 9, 2023
HRSA Virtual Job Fairs are free online recruitment events that connect career seeking health care professionals with representatives across the country.
Learn more about job opportunities, hear details about benefit packages, and find out how you can help underserved communities.
Connect with representatives from 40 health care facilities recruiting for the following vacancies.
- Primary Care Physician (MD or DO)
- Dentist (DDS or DMD)
- Nurse Practitioner (NP)
- Certified Nurse-Midwife (CNM)
- Physician Assistant (PA)
When: august 9 from 6 – 9 p.m. ET
July 11, 2023
Discover Telehealth Trends and Research
As telehealth grows and evolves, Telehealth.HHS continues to add reliable, up-to-date information and resources.
Discover the latest telehealth trends, data and research articles and papers on Telehealth.HHS.gov.
View Telehealth Trends
Telehealth for Behavioral Health Care
July is National Minority Mental Health Awareness Month. Read more about ways patients can use behavioral telehealth services and best practices that providers can follow to deliver quality telehealth care to groups including American Indian and Alaska Native communities.
Telehealth and Behavioral Health
Webinars and workshops are helpful tools to learn more about telehealth and its applications. Visit Telehealth.HHS.gov to find upcoming telehealth events and access registration links.
View Telehealth Events Here