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I said it and I said it for years, and lots of folks challenged me to prove it. Now I can. It is now irrefutably true that CMS Region IV, headquartered in Atlanta, imposes and collects staggeringly more civil money penalties (CMPs) for survey deficiencies than any other CMS region in the nation.

After years of providers telling leaders of the Centers for Medicare & Medicaid Services in Baltimore that CMS Region IV imposes and collects far more civil money penalties for survey deficiencies than any other region, CMS finally has to admit it because the data proves it. And the difference is not just obvious, it’s stunningly disproportionate.

The American Health Care Association recently obtained data from CMS showing the total number of CMPs cited and the total amounts imposed and collected nationally from 2010 to 2012. The data is sorted by CMS region and state, number of CMPs cited, type (per day or per instance), total dollars collected, largest and smallest CMP cited, and other variables.

You can slice and dice this data a hundred different ways, but one thing that stands out indisputably and glaringly is this: of all 10 CMS regions, only five regions imposed more than $1 million in CMPs in 2012. Of those, Region IV (including NC, SC, TN, MS, KY, FL, GA and AL) imposed more than double the total CMPs of any other region. The numbers are staggering; in 2012, counting both per-day and per-instance CMPs, Region IV imposed $18,633,836. The next closest region is Region 6 with a total of $7,896,981, and then Region 5 with $7,484,416. Only two other regions imposed more than $1 million—Regions 1 and 9, at $1,062,184 and $1,288,206, respectively.

The data also shows a steady increase year by year in the CMPs imposed by CMS Region IV. In 2010, Region IV imposed a total of $13,942,889. In 2011, that total increased to $15,931,161 and to $18,633,836 in 2012. Those numbers reflect an increase of roughly $2.3 million in CMPs imposed each year.

Is it possible that the quality of SNF care in the eight states that comprise Region IV is that much worse than in facilities in the entire rest of the nation? That just doesn’t make sense. More to the point, CMS’s own data contradicts such an argument. In 2012, CMS cited 3% of all SNFs in the U.S. with substandard quality of care. In Region IV, the average SQC citation level among all eight states was 2.2%, and that number is that high only because of unusually high SQC citations in Mississippi and South Carolina. Likewise, in 2012, CMS cited 2.2% of all U.S. facilities with immediate jeopardy deficiencies. In Region IV, the average of all eight states was 3.1%, a number that would be lower but for high IJ citations in South Carolina and Tennessee. None of those Region IV deficiency levels even begin to explain why CMS Region IV imposed and collected well over twice the amount of CMPs of any other region in the U.S.

The disparity is so high that you can take numerous combinations of multiple CMS regions and add their CMP totals together, and CMS Region IV still beats them handily in total CMPs imposed for 2012. In fact, if you took all nine CMS regions except Region IV and added together their total CMPs imposed in 2012, that total, covering 42 states, is only $1,055,803 more than the Region IV total alone. The total CMPs imposed by the nine regions excluding Region IV in 2012 was $19,689,639. Region IV alone imposed a total of $18,633,836.

Looking within Region IV at North Carolina specifically, the data is also interesting. Of the eight states in Region IV, North Carolina used the CMP remedy in 2012 107 times, for a total of $2,847,560. The only comparable states in the region were Kentucky which used the CMP remedy 100 times in 2012 and imposed a total of $4,788,358, and Florida, which used the CMP remedy 145 times in 2012 and imposed CMPs totaling $2,501,821. Florida has 682 nursing facilities compared with only 418 in North Carolina yet North Carolina used the CMP remedy almost as frequently as Florida and imposed more total CMPs in 2012.

Outside of North Carolina, Florida and Kentucky, among Region IV states, the CMP remedy was used in 2012 only 18 times in Alabama, 42 times in Georgia, 50 times in Mississippi, 60 times in South Carolina, and 41 times in Tennessee. In 2012, North Carolina imposed the second-highest amount of CMPs among all eight states in Region IV, topped only by Kentucky.

To put these numbers in real terms, if you took the 2012 CMP total of $2,847,560 imposed on North Carolina providers and, just for fun, divided it by the 418 SNFs in North Carolina, that would equate to nearly $7,000 per year in fines imposed by DHSR and CMS against every nursing facility in the state. You can draw your own conclusions about the meaning of this data, but I have a theory about why Region IV is such a glaring outlier among the rest of the nation in terms of frequency of CMP use and total dollars collected from providers. There are only two or three variables that can explain that difference—either (1) the CMP remedy is being used more often in Region IV than in other regions; (2) the per-day CMP amount is markedly higher than in other regions, and/or (3) the duration or length of noncompliance in Region IV is substantially longer than in other regions. These are the only meaningful factors that can explain such an enormous disparity in the level of CMPs collected in Region IV from most other regions, because the number of deficiencies in general cited in Region IV, compared with other regions, does not explain the enormous disparity in total CMPs collected.

To be fair, the amount of CMPs actually “collected” by the various CMS regions is somewhat lower than the amount imposed, likely reflecting waivers of hearings by cited providers (which result in an automatic 35% reduction of the CMP) and settlements through informal dispute resolution or formal appeals that reduce CMPs. For example, in 2012, while Region IV imposed $18,633,836 in CMPs, it collected a total of $16,097,683 or 86% of the CMPs imposed. Other CMS regions had comparable differences in CMPs imposed and collected, so the comparisons made in this article between Region IV and the rest of the CMS regions and the nation don’t change.

I imagine that, like me, a lot of people will be parsing this data more as time goes by to see what else it reveals. At a minimum, it supports the industry’s long-held views that the survey and enforcement processes are woefully lacking in consistency from region to region and state to state and that CMS Region IV is way out of whack with the rest of the country.

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