Hospital quality leaders already strained by the COVID-19 pandemic welcomed the decision from the Centers for Medicare & Medicaid Services (CMS) to delay reporting deadlines for the Merit-Based Incentive Payment System (MIPS) and not require reporting or use data from the initial pandemic period for Medicare quality reporting and value-based purchasing programs for future payment years.

However, there are important issues to consider as hospitals move forward and regroup in the post-pandemic months. It is possible CMS will offer further extensions, even as far as excluding some quality reporting for all of 2020. CMS delayed the March physician reporting period for a month. If the deadline was scheduled for April or May 2020, providers can choose whether to submit data.

For any MIPS provider that did not submit MIPS data by April 30, 2020, CMS will make a neutral payment adjustment for the 2021 MIPS payment year, according to guidance posted by CMS. For 2020 reporting data, CMS has said it is looking at options and will make further announcements.

CMS also said data reporting for fourth quarter 2019 (Oct. 1 through Dec. 31, 2019) is optional. Fourth quarter data, if submitted, will be used to determine performance and payment adjustments. If a hospital chooses not to provide fourth quarter data, CMS will assess performance with data from Jan. 1 through Sept. 1, 2019.

CMS also instructed hospitals not to submit data for Jan. 1 through June 30, 2020, for hospital or post-acute care program performance or payment programs. For some types of healthcare organizations, including home health providers and hospice facilities, CMS extended the non-reporting period through Sept. 30, 2020.

The one-month extension was for physician reporting periods, like the MIPS program, and not directly for hospital reporting programs, explains Anna M. Timmerman, JD, partner with McGuireWoods in Chicago. For hospitals with physician groups, after this one-month extension, CMS has announced enforcement discretion, and reporting will be at the provider’s option.

“In other words, CMS has stated that, for MIPS, if the provider does submit information after this extension, then these data will be used for performance and payment adjustments,” Timmerman explains. “However, if a provider does not submit the information, CMS will give the provider a neutral payment adjustment for 2021 under the MIPS program.”

The CMS changes recognize that during this pandemic, hospitals are focusing on the most immediate, necessary tasks at hand, Timmerman says. Facilities are reassigning staff to ensure care is provided to those hardest hit and that the hospital’s operations are focused on what is needed, she says.

“To the extent data professionals preparing quality reports can assist in other data processing or operations, this direction from CMS, that fourth quarter quality numbers are optional, and that Q1 and Q2 2020 data will not be accepted, will allow such professionals to focus on other, more pressing entity needs. Further, hospitals may also avoid the expense of some third-party vendor costs if no reporting is required,” she says. “Of course, this assumes that hospitals make the determination to simply not report. If hospitals instead want to calculate the data to determine if it would be in their best interest to report, then quality professionals may need to perform the same amount of work to prepare the information necessary for the hospital to make such a determination.”

Report Good Data

If hospitals believe that fourth quarter data will improve its 2019 metrics, then failing to report could be detrimental, says Timothy J. Fry, JD, an associate with McGuireWoods. Hospital administrators may want to proceed with reporting if fourth quarter data would improve its scores. This may assist both their finances and public information.

“On the other hand, it is possible that hospitals will determine that fourth quarter data would harm their 2019 metrics and thus not submit the information. If this determination is made, other hospital providers could see negative adjustments to their payments on a go-forward basis due to Medicare budget neutrality rules,” Fry explains. “Effectively, if everyone submits to maximize their individual facility’s reimbursement, there will be less money for others.”

If the pandemic lasts longer, and CMS takes further alleviation efforts, hospitals should monitor and make determinations in the future, Timmerman advises.

“We expect that providers may begin to raise concerns to CMS on using quality measures for future payments if the no-reporting period extends beyond six months. At some point, if the reported data is limited because there are no applicable measures for an extended period, many hospitals may not view the data as properly validated,” Timmerman says. “In other words, if reporting is only three months, will smaller hospitals have the census where such reporting is properly used for quality payments? At six months, we are not there. But if the extension continues, CMS and providers will likely want to revisit and discuss further.”

Timmerman says she and her colleagues expect CMS to continue to monitor and provide further guidance on reporting in the future. Clearly, CMS is providing flexibility and trying to address acute needs of providers by removing these reporting burdens, she says.

“We would not expect that CMS would begin the pandemic with such flexibility, and then take a different approach later. Ultimately, what happens after these first extensions and options will depend in part on how long the pandemic lasts and what the economic impact on providers is,” Timmerman says. “If the pandemic ends shortly, we would expect CMS to return to reporting and quality measures as quickly as they can. If it lasts longer, we would expect further alleviation efforts.”

Leapfrog Supports Options

The current CMS changes should be helpful when hospitals are under the enormous stress brought on by the pandemic, stresses that will continue after the initial shock and most intense period of the crisis, says Leah Binder, president and CEO of The Leapfrog Group in Washington, DC. Leapfrog also is delaying the deadline on its survey by 60 days, giving hospitals until Aug. 31 to submit surveys.

“Hospitals need other priorities taken off their plate at this time, so we are sympathetic to their need for relief for a brief time in quality reporting,” Binder says. “That said, we would recommend that quality professionals who have the capacity to report these data voluntarily do so. Especially now, hospitals are paying very close attention to infection control and protocols for paying absolute vigilance to following all the rules in a hospital setting. Their data for this period will probably look better than normal.”

Some hospitals will find it infeasible to assemble and report the data because they must prioritize the immediate response to the pandemic, Binder says. Those hospitals should take advantage of the CMS changes without any guilt over failing to report. But other hospitals should not assume that is the right choice before assessing their ability to report.

“Hospitals should be recognized when they are stepping up their safety. Reporting the data is one way to acknowledge the hard work by your physicians and staff who went the extra mile in this time of need. Reporting their success is a way to recognize them,” Binder says. “They also should try to have the most up-to-date information on their safety on their websites and available to CMS. It’s to their great advantage to report the information.”

Old Data Inevitable

Binder worries that if a large proportion of hospitals forgo reporting data, the effect down the road could be that consumers and purchasers will have to rely on old data to make healthcare decisions. Older data are never as valuable as newer data, but there may be no choice for a while. “For a short time, we will have to live with older data. We can do that once, we just shouldn’t do it all the time. We can’t make it a habit, but we’re talking about a one-time thing brought on by extraordinary circumstances,” Binder says. “This isn’t something hospitals should worry about right now. Report the data if you can, but if you can’t, get to work, and save some lives.”

The impact of the CMS decisions could be significant for some hospitals and other healthcare organizations, says Ruth Tabak, associate director at Berkeley Research Group (BRG), a consulting firm in Washington, DC. She previously worked for CMS.

The extensions and exemptions may allow quality professionals to direct their attention and other resources to more pressing needs during and after the pandemic, she says.

“CMS is trying to reduce the administrative burden on hospitals of quality reporting during this extraordinary time. Some hospitals may be able to pivot their quality professionals to higher-priority activities, such as tracking coronavirus patient volume, outcomes, and facility readiness,” Tabak says. “In past natural disasters — for example, hurricanes — CMS has also delayed quality reporting deadlines for providers and plans. We were not surprised to see this as one of the first steps the agency took.”

Hospital quality professionals should consider the potential cost of reporting when deciding whether to take advantage of the CMS changes and delay reporting, or continue as they normally would have, Tabak says.

“It really depends on the hospital. If quality metrics are queued up and ready to submit, hospitals should probably proceed,” she says. “However, if submission will take staff time and resources that could otherwise be redirected to coronavirus response, hospitals should take advantage of the new CMS flexibility — and expect that more is coming.”

Few Risks in Not Reporting

There are likely few, if any, risks for hospitals choosing not to submit quality reporting data under the new CMS guidance, Tabak says. The agency will do anything it can to free up resources for hospitals during the pandemic, and it will not retroactively impose any punitive measures on hospitals that do not report, she adds.

“Depending on the severity and length of the outbreak in the United States, it is likely CMS will offer a second suspension or delay of quality measures, perhaps extending to all of 2020,” Tabak offers. “The agency may also develop specific ‘hold harmless’ policies for hospitals whose performance on certain quality metrics suffers during the period of the pandemic.”

Tabak notes that many of the hospital quality reporting metrics are in statute rather than CMS policy. That means while CMS can grant exceptions and hold providers harmless under its “extreme and uncontrollable circumstances policy,” it is not possible to forgo required quality reporting indefinitely. “In one to two years, we’ll likely be back on regular reporting timelines and performance assessment,” Tabak says.

The benefits of the CMS reporting changes brought quick relief to hospital administrators responsible for quality data collection and management, says Lauren Patrick, president of Healthmonix, an analytics company in Malvern, PA, that assists healthcare organizations in delivering value-based care. The firm also is an official CMS-certified MIPS registry.

“Entire hospital staffs are being called on to address the COVID-19 pandemic. CMS’s rule changes in regard to relaxing the reporting requirements are being felt immediately,” she says. “Many organizations can shift focus from providing data reporting to addressing the unprecedented demands of the pandemic, without worrying about being penalized in the long run for the shift in the near-term focus. CMS should be lauded for their quick, wise response in taking this burden off the hospital quality professionals and essentially all staff in hospitals.”

That immediate relief is yielding to the need for longer-term decision-making, Patrick says. Once the initial demands of the pandemic begin to wane, hospital quality professionals will need to decide longer-term whether to opt out of some of the reporting requirements or take advantage of the extended deadlines that are offered, she says.

That is true not only for current deadline changes but for any further extensions or exemptions CMS may announce, Patrick notes.

Opportunity to Assess

Any CMS changes also could be an opportunity to reassess data and reporting capabilities, using the extra time afforded by CMS to make necessary corrections, Patrick says.

“They will need to evaluate the choices in light of their internal data and the ongoing demands on their staffs. For some, this represents an opportunity to ‘shore up’ some of their reporting. For others, they simply may not have the resources to report,” Patrick says. “We work with many providers that have their 2019 data gathered and their reporting completed, or they are just about finished. For those, it’s an opportunity to perhaps audit their internal data, and improve their reporting by delaying a few weeks for resubmitting.”

In particular, Patrick says quality leaders will have to carefully consider whether to take advantage of the changes for those involved in the QPP MIPS program. That will depend on the data available and potential performance numbers, she says.

“This provides an opportunity to review 2019 data and determine if they meet the minimum performance threshold to qualify for a positive payment adjustment. If their performance is below the neutral payment threshold, 30 points for 2019, then it benefits them to not report at all,” she explains. “If their performance is above the 30-point threshold, and if they have the resources, they should continue to complete their 2019 submission.”

For those that are not close to completing reporting and/or anticipate a low score in the program, it may be best to pass on reporting for the 2019 period, Patrick says, because CMS has removed any risk or disadvantage in not reporting.

“For those that are not complete but feel they can still achieve a high score, it’s to their advantage to utilize the extra time to complete the reporting,” she says. “The only potential disadvantage of not reporting is losing an incentive if a significantly high score would have been achieved.”

One concern for the QPP MIPS program is the potential lack of incentive money for high performers in the program with this change, Patrick says. This program is intended to be a budget-neutral program, which means that the incentives for high performers are funded by the penalties for low performers. “While there is a bucket of money for exceptional performance that the government provides, the amount of money available for high performers will be severely limited if no providers are penalized for not reporting,” she explains.


  • Leah Binder, President and CEO, The Leapfrog Group, Washington, DC. Phone: (202) 292-6713.
  • Timothy J. Fry, JD, Associate, McGuireWoods, Chicago. Phone: (312) 698-4596. Email:
  • Lauren Patrick, Founder and President, Healthmonix, Malvern, PA. Phone: (888) 720-4100.
  • Ruth Tabak, Associate Director, Berkeley Research Group, Washington, DC. Phone: (202) 480-2730. Email:
  • Anna M. Timmerman, JD, Partner, McGuireWoods, Chicago. Phone: (312) 750-8604. Email: