CMS Releases FY 2022 Hospital VBP Program and January 2022 Public Reporting MSPB Measure HSR

2021-5-27

The Medicare Spending per Beneficiary (MSPB) hospital-specific reports (HSRs) for the fiscal year (FY) 2022 Hospital Value-Based Purchasing (VBP) Program review and January 2022 Public Reporting refresh will be delivered no later than Friday, May 28, 2021.

The MSPB measure assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge. The measure includes price-standardized and risk-adjusted payments. Price standardization removes sources of variation that are due to geographic payment differences, such as wage indexes, geographic practice cost differences, indirect medical education, and disproportionate share hospital payments. Risk adjustment accounts for variation due to patient health status.

Updated Performance Period Due to COVID-19 Exception

Calculations of the MSPB measure results in the HSRs are based on an episode restriction period of admission dates after October 2, 2020 and with discharge dates prior to December 1, 2020.

The episode restriction period in this HSR is also updated to reflect the policy finalized in the interim final rule with comment period (CMS-3401-IFC), published on September 2, 2020. The policy states, due to the impact of COVID-19, CMS will not use claims reflecting services provided January 1, 2020, through June 30, 2020, (Q1 and Q2 2020) in its calculations for the Medicare quality reporting and VBP programs. (The entire 90-day lookback period and the entire 30-day post-discharge period of the episode restriction period in the measure methodology must fall within the performance period.)

Hospitals do not need to request an Extraordinary Circumstance Exception (ECE) for measures and submissions covered under the COVID-19 exception for Q1 and Q2 2020. If a hospital believes that their performance continues to be adversely impacted by this extraordinary circumstance beyond June 30, 2020, they can submit an individual ECE request to CMS for the Hospital VBP Program 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.

Note: A granted individual ECE in the Hospital VBP Program would exclude the hospital from the Hospital VBP Program for the entire fiscal year in which performance was impacted. An excluded hospital will not incur the 2-percent reduction in payments, but it would also not receive incentive payments for the fiscal year. Additional information regarding ECE requests for the Hospital VBP Program can be accessed on QualityNet.

Accessing the HSR

CMS will distribute the HSRs through CMS Managed File Transfer (MFT) no later than Friday, May 28, 2021. HSRs will be provided to users at a hospital that have approved Auto-Route (IQR) and Managed File Transfer permissions associated with their Hospital Quality Reporting (HQR) profile.

If you are not a Security Administrator/Official for your hospital or you have not recently taken action to request these permissions on your account, you will not have the permissions on your profile required to receive an HSR.

Reference the Important: Request Access to Managed File Transfer (MFT) & Auto-Route Now to Ensure You Receive Your Reports email notification released on March 18, 2021, for instructions to request these permissions or to confirm these permissions are active on your profile.

When your MFT mailbox receives your hospital’s report, a notification will be sent to the email address associated with your HCQIS Access Roles and Profile (HARP) account. At that point, please follow the steps below to access your HSR in your MFT mailbox:

Navigate to the CMS Managed File Transfer page at https://qnetmft.cms.gov/mft-signin/login.
Enter your HARP User ID and Password. Select the I agree to the Terms and Conditions checkbox. Then, select Sign In.
You will be directed to the Two-Factor Authorization page. A preview of the device or email that will be sent a code will be displayed. Select Send Code. After selection, the Send Code button will update to Sent.
After receipt of the code via your device or email, enter the code. Then, select Verify.
Upon successful login, you will be directed to the MFT dashboard. Select Mail on the left-navigation pane to expand the mailbox.
Select Inbox under the expanded Mail options.
This HSR will have a subject of AutoRoute – Package 999999_FY2022_MSPB_HSR with your hospital’s six-digit CMS Certification Number (CCN) replacing 999999. Open the message containing the HSR by clicking on that line.
Download the HSR by selecting the file in the Attachments section of the message.

HSRs will be available in your MFT mailbox for thirty (30) days after delivery.

If, after May 28, 2021, you have not received an email notifying you of the report delivery and you believe your profile has the appropriate permissions, follow the instructions above to check if the report was delivered. If the report was not delivered, confirm that your profile has the permissions required to receive the report, as detailed above.

If your profile did not have active Auto-Route (IQR) and MFT permissions prior to May 27, 2021, you may request these permissions now by following the instructions detailed in the previously mentioned QualityNet news article. Your hospital’s Security Administrator/Official will review your requested permissions. Once you have been granted the proper permissions you will have access to any future report deliveries via MFT; however, this report will not be available unless a request to resend the report is submitted.
If your profile did have active Auto-Route (IQR) and MFT permissions prior to May 27, 2021, and you did not receive your report, please contact the QualityNet Help Desk for further assistance at qnetsupport@hcqis.org.

Requests to resend the report can be submitted through the Questions and Answers tool on QualityNet:

When submitting the request, select Inpatient Claims-Based Measures from the Program drop-down menu and select Request for hospital-specific report from the Medicare Spending Per Beneficiary (MSPB) topic drop-down menu.
In the subject line, type Request to Resend FY 2022 MSPB HSR. Please describe your question in the text box and include your hospital’s CCN.

If you experience issues accessing your HSR from MFT or requesting and reviewing your HARP permissions, contact the CCSQ Service Center at qnetsupport@cms.hhs.gov or (866) 288-8912.

Review and Correction Period Requests

CMS is providing HSRs for the Hospital VBP Program mortality and complication measures review and correction period that ends at 11:59 p.m. Pacific Time (PT) on Tuesday, June 29, 2021. This review and corrections process does not allow hospitals to submit additional corrections related to the underlying claims data or add new claims to the data extract used to calculate the results. The HSRs are designed to provide hospitals the opportunity to review measure results, check episode data used in the calculation of the claims-based measures and replicate their results. Discrepancies or concerns regarding the claims or results included in the HSRs must be reported during the review and correction period to be considered by CMS. Any requests for the adjustment of claims, measure results, measure scores, or notation of those measure results will not be considered if the request is submitted after Tuesday, June 29, 2021.

Review and correction period requests can be submitted through the Questions and Answers tool on QualityNet. When submitting the request, select Inpatient Claims-Based Measures from the Program drop-down menu and select Review & correction request from the Medicare Spending Per Beneficiary (MSPB) topic drop-down menu. In the subject line, type FY 2022 Hospital VBP Program MSPB HSR Review and Correction Request. In the please describe your question text box, include your hospital’s CCN and your question or request for correction.

Note: Do not email HSR files or their contents. HSRs contain discharge-level data protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any disclosure of protected health information (PHI) should only be in accordance with, and to the extent permitted by, the HIPAA Privacy and Security Rules and other applicable law. Use the ID number found within the HSR when referring to the contents of that report.

January 2022 Public Reporting Preview Period

CMS is also providing the HSRs for the January 2022 Public Reporting preview period. Hospitals have an opportunity to preview their data for 30 days prior to the public reporting of measure results. This preview period does not allow hospitals to submit additional corrections related to the underlying claims or to add new claims to the data extract used to calculate the measure results.

Available Resources

Additional information regarding the MSPB measure methodology and calculations are available on the MSPB Measure QualityNet page.

Educational Webinar and Tutorial Video

On Tuesday, June 8, 2021, at 2 p.m. Eastern Time (ET), CMS will host an educational webinar. Reviewing Your FY 2022 Hospital VBP Program and January 2022 Public Reporting MSPB Hospital-Specific Report will provide an overview of the MSPB measure and HSRs, including the goals of the MSPB measure, the measure methodology, and the steps to perform MSPB measure calculations. Additionally, participants will be provided with instructions for submitting a review and correction request and accessing the MSPB HSRs from MFT. You may register for the webinar here. The presentation slides and recording will be available after the presentation on the Hospital VBP Archived Events page of QualityReportingCenter.com.

Contacts for Questions

Questions regarding the measures, HSRs, and the Hospital VBP Program can be submitted through the Questions and Answers tool on QualityNet. Please include your hospital’s six-digit CCN for all questions and use the following associated program and topic selections when submitting your questions through the tool:

Question Topic: MSPB measure methodology
- Program Selection: Inpatient Claims-Based Measures
- Topic Selection: Medicare Spending Per Beneficiary (MSPB) > Measure methodology
Question Topic: Data or calculations in the HSR
- Program Selection: Inpatient Claims-Based Measures
- Topic Selection: Medicare Spending Per Beneficiary (MSPB) > Question about results
Question Topic: Review and correction request
- Program Selection: Inpatient Claims-Based Measures
- Topic: Medicare Spending Per Beneficiary (MSPB) > Review & correction request
Question Topic: Request to resend an HSR
- Program Selection: Inpatient Claims-Based Measures
- Topic Selection: Medicare Spending Per Beneficiary (MSPB) > Request for hospital-specific report
Question Topic: Hospital VBP Program, COVID-19 Exception, and Individual ECE Requests
- Program Selection: HVBP – Hospital Value Based Purchasing
- Topic Selection: General information (HVBP)
Public Reporting Preview Reports
- Program Selection: Public Reporting & Preview Period
- Topic Selection: Inpatient Hospital

If you experience issues accessing your HSR from MFT or requesting and reviewing your HARP permissions, contact the CCSQ Service Center at qnetsupport@cms.hhs.gov or (866) 288-8912.

For further assistance regarding the information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team by submitting a question through the Questions and Answers tool on QualityNet or by calling (844) 472-4477.