Hospital price transparency
Corrective action plans: the clocks
A corrective action plan has two different clocks: submitting the plan and completing the corrections. Mixing them up can leave a hospital with a timely document but unresolved violations. Under 45 CFR 180.80, the hospital must submit the CAP in the required form and manner by the deadline specified in the notice.
CMS's April 2023 enforcement update says CAP submission remains due within 45 days after CMS issues the CAP request, and full compliance is required within 90 days after that request. The 90 days are not an additional period beginning when the hospital submits its plan. These are CMS process-policy timelines; the actual notice remains the operational source for the hospital's dates.
The CAP must identify the corrective actions or processes that address the deficiencies and the timeframe for completing them. It is subject to CMS review and approval. CMS may monitor and evaluate whether the hospital actually carries out the approved corrections.
CMS's process update describes re-review before imposing a penalty when a hospital misses the submission deadline or fails to meet the CAP terms by the compliance deadline. Recommended practice is to track submission evidence and correction evidence separately, with named owners and dated tests of the public result. Filing a plan alone does not establish compliance.