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Data Collection as a Medicare Condition of Participation

The Centers for Medicare & Medicaid Services (CMS) announced new Medicare condition of participation (CoP) requirements for hospitals to report COVID-19 cases and related data to the Department of Health and Human Services.

In the interim final rule, CMS establishes that hospitals and critical access hospitals are required to report certain information, at a frequency and in a standardized format, as specified by HHS during the COVID-19 public health emergency. Required data include, but are not limited to, number of staffed beds; number of ICU beds occupied; information about supplies, such as ventilators and personal protective equipment; and current number of laboratory-confirmed COVID-19 patients.

As of July 15, hospitals no longer report COVID-19 data through the Centers for Disease Control and Prevention’s National Healthcare Safety Network. Rather, hospitals have been voluntarily reporting COVID-19 data on patient impact and hospital capacity, either through Teletracking or to states that have assumed reporting responsibility on behalf of the hospital.

Other policies in the interim final rule include:

  • new reporting requirements for labs;
  • limitation on repeated testing without a physician order;
  • updates to the extraordinary circumstances exceptions for hospital quality reporting programs;
  • updates to the Merit-based Incentive Payment System; and
  • new testing requirements for nursing homes.

The interim final rule with comment period is effective upon publication in the Federal Register. Comments are due 60 days after publication.

America’s Essential Hospitals is analyzing the interim final rule for comment and will send members a detailed Action Update in the coming days.

Contact Senior Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

Maryellen Guinan is a principal policy analyst at America's Essential Hospitals.

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