Health Law Daily Wrap Up, HOSPICE—PRRB DECISIONS: Hospice quality reporting requirements make internal submission errors noncompliant with FY 2024 payment update standards, (Jul 9, 2026)

By WK Editorial Staff

A hospice that repeatedly uploaded incorrect HIS files did not satisfy HQRP reporting requirements, and the four percentage point annual payment update reduction applied.

The Provider Reimbursement Review Board (PRRB) concluded that the hospice center did not submit quality data in the form and manner, and at the time, specified by the Secretary, so CMS properly reduced the hospice’s fiscal year 2024 annual payment update by four percentage points. The Board based its decision on the structure of the Hospice Quality Reporting Program, which conditions the full payment update on timely submission of required quality data and imposes a four percentage point reduction for fiscal year 2024 and later years when a hospice does not comply. Because the record showed that the hospice failed to meet the 90 percent timeliness threshold for calendar year 2022 Hospice Item Set (HIS) reporting, the Board treated the reduction as the required consequence of noncompliance. The decision turned on the gap between the provider’s internal handling of the data and the program’s precise reporting rules, which require actual submission of compliant data through CMS’s designated systems within 30 days of admission or discharge (Hospice Care Corp., PRRB No. 2026-D19, Case No. 24-0168 (June 25, 2026)).

Governing statute and regulation require a hospice center to submit quality data in a form and manner, and at a time, specified by the Secretary. The regulations require Medicare-certified hospices to complete and submit admission and discharge HIS records for each patient, and the guidance cited by the Board states that a hospice must meet or exceed a threshold of 90 percent of all required HIS records submitted within 30 days of the beneficiary’s admission or discharge to avoid the payment reduction. The Board treated those requirements as objective benchmarks. It explained that relief depended on proof of actual compliance with the time, form, and manner requirements. The record instead showed that the hospice admitted it failed to reach the 90 percent threshold and attributed that outcome to a technical glitch in its own reporting process. According to the evidence, the hospice collected the required information, entered it into a third-party vendor’s site, received a compressed file formatted for submission, saved that file to a thumb drive, and then used the thumb drive to submit the data to CMS. The error occurred because new data did not properly save on the thumb drive and older data was uploaded instead for 2022. In the Board’s view, that explanation confirmed noncompliance because the correct data was not the data actually submitted to CMS in the required way and within the required timeframe.

The Board also relied on CMS submission guidance to explain why the provider’s account did not establish compliance. The HIS Submission User’s Guide states that users must wait for confirmation that a file was successfully uploaded and that the system provides a confirmation message identifying the submission ID, submission date, and file name. The guidance further states that within 24 hours of a successful submission, the QIES ASAP Hospice system validates the file structure and data content and makes a Final Validation Report available in the CASPER Reporting application. That report details any errors found in the submitted file, including duplicate record errors. The Board used that guidance to show that the system includes mechanisms to confirm receipt and to identify validation problems that may affect a submission. The record showed that those mechanisms were not used effectively. A witness admitted that the hospice could have used the CASPER Reporting application to validate that the submission was correct, but did not do so because the witness did not know how. The Board also noted testimony indicating that staffing shortages and insufficient training contributed to a cumbersome file-handling process in which staff repeatedly uploaded the same file without recognizing the mistake. Those facts supported the Board’s finding that the failed reporting stemmed from the provider’s internal practices rather than from a deficiency in the CMS submission system.

The provider asked the Board not to enforce the payment reduction under the circumstances, but the Board rejected that request for two related reasons. First, the regulations create a specific exceptions and extensions process for extraordinary circumstances beyond the control of the hospice, and that process requires a hospice to request relief from CMS within 90 days of the extraordinary circumstance. The Board found that no such request was submitted. In the Board’s view, that omission foreclosed relief because the provider sought relief that depended on procedures it had not timely invoked. The Board stated that granting relief in that posture would thwart the administrative remedy exhaustion requirements applicable to the quality reporting program. Second, the Board explained that even if an extraordinary circumstances request had been made and the matter were properly before it, the evidence still would not show circumstances beyond the hospice’s control. The testimony instead showed an internally created problem tied to staffing shortages, insufficient training, and a multi-step process that caused repeated uploads of the same file. The Board therefore declined to treat the submission failure as an extraordinary event warranting mitigation. It also stated that its jurisdiction is strictly confined to statutory and regulatory requirements and the relevant facts, and that it does not possess equitable authority in these appeals. On that basis, the Board concluded that CMS correctly assessed the four percentage point reduction in the hospice’s fiscal year 2024 payments.

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