Monday Morning Rounds with CMS

ICYMI, here is recent communication from CMS.


May 2022 CMS Quality Programs Bi-Monthly Forum
When: Tuesday, May 10, 2022 1:00 – 2:00 pm ET
Register for this event.

During this webinar, attendees will learn important updates relevant to CMS’s Quality Measurement and Value-Based Incentives Group (QMVIG). The forum will also provide stakeholders with the opportunity to ask CMS subject matter experts questions on quality reporting programs and initiatives that directly impact their organizations.

This forum will include updates on the following topics:

  • The Medicare Promoting Interoperability Program;
  • Electronic Clinical Quality Measures (eCQMs) Annual Update;
  • Quality Reporting Document Architecture (QRDA) Implementation Guide;
  • July Fast Healthcare Interoperability Resources® (FHIR) Connectathon;
  • CMS Digital Quality Measures Webpage;
  • The CMS Measures Inventory Tool;
  • The Quality Payment Program (QPP); and
  • Alternative Payment Models (APMs).


Submit Comments on Episode-Based Cost Measure Comprehensive Reevaluation Now through May 28, 2022
CMS and its contractor, Acumen, LLC, are gathering input on eight episode-based cost measures being considered for comprehensive reevaluation through a Call for Public Comment. The measures included in this Call for Public Comment are those that were added to the MIPS in performance year 2019. Stakeholders are invited to submit their feedback in response to the information and questions included in the document between now and May 28, 2022, at 11:59 p.m. ET.

Register for the CMS Web Interface and the CAHPS for MIPS Survey Quality Reporting for the 2022 Performance Period by June 30, 2022
Registration is now open for the CMS Web Interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey for the 2022 performance period.

  • Groups, virtual groups, and Alternative Payment Model (APM) Entities with 25 or more clinicians (including at least one MIPS eligible clinician) can register through June 30, 2022, to use the CMS Web Interface for reporting quality measures under traditional MIPS.
  • Groups, virtual groups, and APM Entities with 2 or more clinicians (including at least one MIPS eligible clinician) can register through 2022 to administer the CAHPS for MIPS Survey under traditional MIPS or the Alternative Payment Model (APM) Performance Pathway (APP).
  • Groups, virtual groups and APM Entities only need to register if they intend to report through the CMS Web Interface and/or administer the CAHPS for MIPS Survey for the 2022 performance period.

To register, please log in to the Quality Payment Program (QPP) website. You’ll need to have the Security Official role in order to register your organization. Please refer to the QPP Access User Guide (ZIP) for information about obtaining a Security Official role for your organization. You can register by:

  • Signing in to QPP.
  • Going to the Manage Access page.
  • Clicking “Edit Registration” by 8 p.m. ET on June 30, 2022.


New Data and Report on Hospital and Nursing Home Ownership
The HHS is taking actions to promote competition and transparency in our nation’s health care system that can improve the safety and quality of nursing homes and hospitals. CMS is releasing data publicly — for the first time — on mergers, acquisitions, consolidations, and changes of ownership from 2016-2022 for hospitals and nursing homes enrolled in Medicare. This data is a powerful new tool for researchers, state and federal enforcement agencies, and the public to better understand the impacts of consolidation on health care prices and quality of care.

CMS Proposes Policies to Advance Health Equity and Maternal Health, Support Hospitals
CMS issued a proposed rule for inpatient and long-term hospitals that builds on the Biden-Harris Administration’s key priorities to advance health equity and improve maternal health outcomes. In addition to annual policies that promote Medicare payment accuracy and hospital stability, the FY 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) rule includes measures that will encourage hospitals to build health equity into their core functions, thereby improving care for people and communities who are disadvantaged and/or underserved by the healthcare system. The rule includes three health equity-focused measures in hospital quality programs, seeks stakeholder input related to documenting social determinants of health in inpatient claims data, and proposes a “Birthing-Friendly” hospital designation.

CMS Announces New Cross-Cutting Initiatives
CMS announced a series of Cross-Cutting Initiatives (CCIs) that will drive the Centers’ and Offices’ strategic vision to advance health equity, expand coverage, and improve health outcomes. In addition to advancing the six strategic pillars that CMS announced last year, the CCIs aim to improve behavioral and maternal health coverage, drug price affordability, and rural health care delivery along with strengthening quality improvement strategies and ensuring coverage for eligible individuals post-pandemic.

$90 Million to Support New Data-Driven Approaches for Health Centers to Identify and Reduce Health Disparities
The HHS through the Health Resources and Services Administration (HRSA), announced the availability of nearly $90 million in American Rescue Plan funding to support new data-driven efforts for HRSA Health Center Program-supported health centers and look-alikes (HRSA-designated health centers) to identify and reduce health disparities.

CMS Returning to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities
CMS is taking steps to continue to protect nursing home residents’ health and safety by announcing guidance that restores certain minimum standards for compliance with CMS requirements. Restoring these standards will be accomplished by phasing out some temporary emergency declaration waivers that have been in effect throughout the COVID-19 Public Health Emergency (PHE). These temporary emergency waivers were designed to provide facilities with the flexibilities needed to respond to the COVID-19 pandemic.

CMS Finalizes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
CMS released a national policy for coverage of aducanumab (brand name Aduhelm™) and any future monoclonal antibodies directed against amyloid approved by the FDA with an indication for use in treating Alzheimer’s disease. From the onset, CMS ran a transparent, evidence-based process that incorporated more than 10,000 stakeholder comments and more than 250 peer-reviewed documents into the determination.

Administration Announces a New Way for Medicare Beneficiaries to Get Free Over-the-Counter COVID-19 Tests
The Biden-Harris Administration announced that more than 59 million Americans with Medicare Part B, including those enrolled in a Medicare Advantage plan, now have access to Food and Drug Administration (FDA) approved, authorized, or cleared over-the-counter COVID-19 tests at no cost. People with Medicare can get up to eight tests per calendar month from participating pharmacies and health care providers for the duration of the COVID-19 public health emergency.

Quality Payment Program

Promoting Interoperability

Medicare Promoting Interoperability Program 2022 Specification Sheets are now Available
CMS has released the specification sheets for the 2022 Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs). The specification sheets provide a guide to the program’s measures. scoring details, and additional resources for participating eligible hospitals and CAHs.

“Medicare and Medicaid Promoting Interoperability Programs” becomes “Medicare Promoting Interoperability Program for eligible hospitals and CAHs” after ending of Medicaid Promoting Interoperability Program
With the Medicaid Promoting Interoperability Program ending in program year 2021, CMS has changed the Medicare and Medicaid Promoting Interoperability Programs name to the Medicare Promoting Interoperability Program for eligible hospitals and CAHs.” Previously, information distributed under the Promoting Interoperability Programs listserv was for participants of either program. Moving forward, information distributed through this listserv will be only relevant for eligible hospitals and critical access hospitals participating in the Medicare Promoting Interoperability Program.

Administrative Simplification

Administrative Simplification Enforcement and Testing Tool
The Administrative Simplification Enforcement and Testing Tool (ASETT) is now available for use through the CMS ID Management (IDM) system.

You can use ASETT to file a complaint with the CMS National Standards Group (NSG) about alleged violations of the HIPAA Administrative Simplification requirements.

Compliance Review Program Findings
The CMS National Standards Group, on behalf of HHS, administers the Compliance Review Program. The program aims to promote compliance with HIPAA Administrative Simplification rules for electronic health care transactions. Since the program launched in April 2019, NSG has conducted 20 compliance reviews with a mix of clearinghouses and health plans.

To help covered entities prepare for compliance reviews, CMS has created a report with the most common violations of standards and operating rules from the reviews.

Find out more about the Compliance Review Program on the Administrative Simplification website.

CMS Innovation Center