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Medicare Mandatory Reporting Requirements

Medicare mandatory reporting requirements assure that the Centers for Medicare and Medicaid (CMS) have feedback data to improve and refine regulations of health care services. In addition, CMS is also looking to reporting requirements to allow it to transform from a passive purchaser of health care into an active purchaser of high quality care that can make purchase decisions based on collected data.

  1. Hospital Reporting Requirements

    • Hospitals operate under a multitude of reporting requirements. For example, hospitals are required to report hospital-acquired conditions (HAC) and present on admission (POA) information for all primary and secondary diagnoses of patients admitted to the facility. In addition, hospitals are required to report quality care data for annual payment update purposes. This program will be expanded starting in 2011 to include surgical care, stroke care and nursing care.

      The quality of care reporting requirements echo practice guideline factors to assure proper care is provided to Medicare beneficiaries. For example, if a patient presents with a heart attack, a hospital will report whether it complied with various steps such as providing medications on arrival and at discharge, along with proper treatment and counseling.

    Non-Hospital Reporting Requirements

    • A new effort by CMS is to assure Medicare's status as secondary payer when appropriate. Under Section 111 of the Medicare, Medicaid and SCHIP extension Act of 2007 (MMSEA) new mandatory reporting requirements were enacted for group health plans along with multiple types of insurance entities (liability insurance, no-fault insurance and worker's compensation).

      The goal of requiring mandatory reporting for insurance entities is to assure CMS is aware of all bodily injury and medical payments involving Medicare-eligible claimants, so CMS can determine primary or secondary payer responsibility for a Medicare covered beneficiary.

    Reporting Issues

    • Reporting is generally electronic in nature and intended to be no more than quarterly in frequency. Failure to make mandatory reports results in penalties of $1,000 per day per reportable Medicare claim. Since health care generally involves large numbers of individual claims, this penalty could quickly become an enormous penalty where a provider fails to comply with reporting requirements.

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