Empower Clinical Informaticists for Reimbursement Wins in 2025

With the IPPS Final Rule, Medicare inpatient payment system rates were raised by a net of 2.9% for hospitals that meet regulatory compliance with their quality measures data. The ruling also ramped up expectations related to quality measures, number of programs, frequency of reporting, and financial stakes. Hospital leaders and informaticists may find themselves stretched thin ensuring the data and workflows for new compliance requirements and ensuring maximum reimbursement. Add the pressure of avoiding disincentives that could apply, and the struggle intensifies.  This blog can help your hospital find resources for preparing for a new era in regulatory reporting.

Understanding the Increased Regulatory Demand 

The 2025 IPPS final rule introduces several new quality measures and reporting requirements that will impact hospitals reimbursement rates. Informatics and compliance professionals will need to manage more frequent data submissions, ensure data accuracy, and integrate new measures into existing workflows. New reporting requirements for new measures apply, as do disincentives hinging on new and/or validated data collection. We’ve summarized findings of our study of the requirements in our Regulatory Programs Chart, and some of the measurement and reporting changes include: 

• Antimicrobial Use and Resistance Reporting: This will now be split into two separate measures, requiring monthly data submissions for both antimicrobial use (AU) surveillance and antimicrobial resistance (AR) surveillance. 

• Hospital Harms Measures: New measures such as falls with injury and post-operative respiratory failure will be introduced. Additionally, excessive radiation dose for adults will become an optional measure in 2025, likely becoming mandatory in the future. 

• Increased Reporting Frequency: The number of required and self-selected clinical quality measures will increase over the next few years. Some measures are now mandatory to be reported on weekly/monthly/quarterly frequency, where they may have only been annual in the past. For example, by 2026, facilities will need to report on eight required and three self-selected measures, up from the current three and three. 

• Data Accuracy Requirements: Starting in 2025, quality measure content will be evaluated for accuracy with a minimum threshold of 75%. This means that not only must data be submitted, but it must also be validated and accurate. 

• TEAM (Transforming Episode Accountability Model): This model aims to reduce Medicare overspending by holding facilities accountable for patient outcomes post-surgery. Facilities will need to track patients through their post-operative care, ensuring no readmissions, shorter hospital stays, and proper follow-up appointments. The model will be piloted in 2026, with different tracks offering varying levels of risk and reward based on compliance and performance. 

• Pro-PM (Patient-Reported Outcome Performance Measures): This includes measures for hospital-level total hip and total knee patient-reported outcomes. Data collection spans pre-operative and post-operative periods, with specific timelines for submission. Facilities will need to gather patient-reported data through surveys and ensure accurate reporting to CMS. 

Advocating for Clinical Informaticists 

With the new requirements set to impact FY 2025 reimbursements, the workload for clinical informaticists has already increased significantly. Consider these strategies to advocate for your clinical informaticists ensuring your organization meets the new demands effectively to comply with regulatory requirements, to assure reimbursement, and to avoid informaticist burnout. 

1. Highlight the Importance of Their Role: Emphasize the critical role clinical informaticists play in ensuring compliance with regulatory requirements and improving patient outcomes. Their expertise in managing electronic health records (EHRs) and data analytics is essential for meeting the new quality measures. 
2. Provide Adequate Resources: Ensure that your clinical informaticists have access to the necessary tools and technologies. This includes up-to-date EHR systems that support the latest reporting requirements, such as USCDI v3. 
3. Invest in the EHR and Professional Development: Compliance is dependent on data that is collected through the EHR's clinical workflows. You may need to invest in EHR assessment and optimization, or user training to ensure that your organization is prepared to demonstrate best practices in clinical care that meet the highest compliance rates. 
4. Foster a Collaborative Environment: Encourage collaboration between clinical informaticists and other departments, such as quality improvement and patient safety teams. This can help streamline workflows and ensure that all stakeholders are aligned in meeting regulatory requirements. 

Investing in Regulatory Compliance Success 

1. Augment Staff with Regulatory Experts: To manage the increased workload, consider staff augmentation with expertise in regulatory reporting and compliance. While many vendors provide platforms and a specific set of reports, these professionals can help share the burden of extracting and monitoring data, setup and review for new quality measures and reporting requirements, and coordination that extends the capacity of your internal informatics team. Augmentation could be a particularly interesting option for the 700+ facilities named on the Transforming Episode Accountability Model (TEAM) selected facilities list (excel file to open from https://www.cms.gov/team-model-participant-list).
2. Leverage Financial Incentives: Highlight the potential financial benefits of meeting the new quality measures and the potential disincentives. While achieving compliance can result in a 2-3% increase in reimbursement rates, a disincentive could erase that margin and more. Analyzing the tradeoffs could justify the investment in additional staff and resources. 
3. Plan for Long-Term Data Collection: Some of the new reporting requirements will necessitate years of data collection. Ensure that your organization is prepared for this long-term commitment by allocating the necessary resources and planning ahead. 

Empowering your organization is a crucial step to navigating the new quality measures and reporting requirements. By providing the necessary resources, you can ensure that your organization meets these demands effectively, ultimately improving patient outcomes and securing financial incentives. 

CereCore Services for Regulatory Reporting and Submissions

We have found that the most cost effective approach leverages core EHR components, solid workflows and data review, and platforms such as SQL and PowerBI that are most often already part of the hospitals technology stack. This reduces common challenges with data coordination  with other vendors and platforms, as well as reduces costs. While our comprehensive program includes turnkey implementation, monitoring, validation, alerting/auditing, and trend analysis on all CMS and CDC major regulatory programs, this list of services can be viewed as best practices for a robust regulatory reporting program:

Editors note: Our recap of regulatory reporting changes is intended to help prepare hospitals for what's ahead and offer alternatives for filling gaps in internal resources, but is not to be considered complete guidance. Refer to official documentation from CMS including 2025 IPPS final rule, the final rule fact sheet, the TEAM fact sheet, and the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule).

For More Information 

• MEDITECH Assessment
• CereCore Regulatory Submissions Program Video 
• Regulatory Reporting Services at CereCore