United States: Analysis And Impact Of The Improving Medicare Post-Acute Care Transformation Act Of 2014

This week, President Obama signed into law the Improving Medicare Post-Acute Care Transformation Act of 2014 (the "IMPACT Act" or "Act").1 The IMPACT Act's provisions will affect a broad range of post-acute care ("PAC") providers: home health agencies ("HHAs"), skilled nursing facilities ("SNFs"), inpatient rehabilitation facilities ("IRFs"), and long-term acute care hospitals ("LTCHs"). Various facets of daily operations of these PAC providers will change as a result of the Act: what information PAC providers must collect and report, the information the public will receive about PAC providers, and even the method of determining future Medicare payments to PAC providers, among others.

Policymakers have long expressed concerns with the disparate methods of paying for PAC services that may, to some degree, be substitutes for one another or complements to each other.2 According to the preamble of the bill, the Act is intended to provide standardized assessment data for quality improvement, payment, and discharge planning purposes across the spectrum of PAC providers.

The IMPACT Act has four stages of implementation: (1) the data collection, reporting, and analysis stage; (2) the feedback report stage; (3) the public report stage; and (4) the Congressional report stage. First, the PAC providers affected by the IMPACT Act must collect and report various types of data on Medicare beneficiaries in their care using prescribed assessment instruments. The Secretary of Health and Human Services ("HHS"), and more likely her designee, the Centers for Medicare & Medicaid Services ("CMS"), then analyzes that data. Second, the Secretary provides the PAC providers with a feedback report, analyzing the PAC providers' performance on the metrics measured. Third, the Secretary releases the data on the PAC providers' performance to the public. Finally, the Secretary and the Medicare Payment Advisory Commission ("MedPAC") submit reports to Congress recommending future payment plans for PAC providers, and analyzing their effect on the metrics measured, as well as any financial effects.

The IMPACT Act could significantly increase the burden on PAC providers to maintain and report more data and clinical measures on each individual patient. At the same time, the law gives the Secretary some discretion in adding or removing factors from the collection, analysis, and reporting mandated, which presents PAC providers with the opportunity to work with CMS on the development and implementation of the new reporting systems. In the long-term, the IMPACT Act aims to provide a foundation of data upon which Congress can debate possible changes to the Medicare payment system for PAC providers.

In addition to the above-noted data collection and reporting provisions, the IMPACT Act makes several changes important to Medicare-certified hospice programs, including more frequent surveys, clarification on when medical reviews are performed, and a change in the annual process to calculate the payment cap that limits each hospice provider's aggregate Medicare payments per year.

DATA COLLECTION, REPORTING, AND ANALYSIS

Under the IMPACT Act, PAC providers must collect and report to HHS standardized and interoperable patient assessment data, quality measures, and resource use measures. Rather than mandate a single assessment tool for all PAC providers, the Act requires the use of separate, but uniform, assessment instruments to collect and report the patient assessment data, quality measures, and resource use measures.3 This approach is intended to facilitate the submission of standardized data, capable of comparison across all PAC providers (i.e., interoperability).

HHAs must collect and report the data and measures using the Outcome and Assessment Information Set, commonly referred to as OASIS.4 SNFs must collect and report the data and measures using the Resident Assessment Instrument/Minimum Data Set.5 IRFs must collect and report the data and measures using the IRF-Patient Assessment Instrument. LTCHs must collect and report data and measures using the LTCH-Continuity Assessment Record and Evaluation.

Reporting Patient Assessment Data

PAC providers must begin reporting patient assessment data in a standardized and interoperable format according to a specific schedule outlined in the Act. SNFs, IRFs, and LTCHs must begin reporting this data no later than October 1, 2018. HHAs must begin reporting this data no later than January 1, 2019.

The standardized and interoperable patient assessment data that PAC providers must report are defined as, at least: (1) functional status; (2) cognitive function and mental status; (3) special services, treatments, and interventions required; (4) medical conditions; and (5) impairments. The Secretary is granted the authority to require reporting of other categories of patient assessment data as deemed necessary and appropriate. PAC providers must report this data at admission and discharge of a patient, and more frequently if the Secretary deems appropriate.

The Secretary will match any available claims data for individual patients with their assessment data. For SNFs, IRFs, and LTCHs, the Secretary will match this data by October 1, 2018, to the extent practicable. For HHAs, the Secretary will match the data by January 1, 2019, to the extent practicable. The Secretary will use this matched data for the purpose of assessing prior service use and concurrent service use, and the Secretary may also use the data for other uses deemed appropriate. The Secretary and HHS cannot, however, use the matched claims and assessment data to require that individuals receive post-acute care from a specific type of provider to be eligible for payment.

Reporting Quality Measures and Resource Use Measures

In addition to the patient assessment data, PAC providers must begin reporting quality measures and resource use measures in a standardized and interoperable format.

Quality Measures Defined

The quality measures that PAC providers must report are defined as, at least:

  • Functional status and cognitive function, and changes in function
  • Skin integrity and changes in skin integrity
  • Medication reconciliation
  • Incidence of major falls
  • Accurately communicating the existence of, and providing for, the transfer of an individual's health information and care preferences to the individual and others in charge of caring for, or providing services for, the individual when:

    • The individual transitions from a hospital or critical access hospital to another PAC provider or the individual's home, or
    • The individual transitions from a PAC provider to another applicable setting (including a different PAC provider, a hospital, a critical access hospital, or the home of the individual)

The Secretary may require reporting other necessary quality measures data. The Secretary also may remove, suspend, or add a quality measure or resource use measure, as long as the Secretary publishes a justification in the Federal Register.

The timelines for PAC providers to begin reporting on quality measures is summarized below in Table 1.

Table 1: Timeline for Reporting Quality Measures
Quality Measures HHAs SNFs IRFs LTCHs
Functional Status 1/1/2019 10/1/2016 10/1/2016 10/1/2018
Skin Integrity 1/1/2017 10/1/2016 10/1/2016 10/1/2016
Medication Reconciliation 1/1/2017 10/1/2018 10/1/2018 10/1/2018
Major Falls 1/1/2019 10/1/2016 10/1/2016 10/1/2016
Patient Health Information and Preference 1/1/2019 10/1/2018 10/1/2018 10/1/2018

Resource Use Measures Defined

The resource use measures that PAC providers must report are defined as, at least: (1) total estimated Medicare spending per beneficiary; (2) discharge to community; and (3) measures to reflect all-condition, risk-adjusted, potentially preventable hospital readmission rates. The Secretary may require reporting of other categories of resource use measures as deemed necessary.

SNFs, IRFs, and LTCHs must begin reporting resource use measures in a standardized and interoperable format no later than October 1, 2016. HHAs must begin reporting resource use measures no later than January 1, 2017, as indicated in the following table:

Table 2: Timeline for Reporting Resource Measures
Resource Use Measures HHAs SNFs IRFs LTCHs
Resource Use Measures 1/1/2017 10/1/2016 10/1/2016 10/1/2016
Discharge to Community 1/1/2017 10/1/2016 10/1/2016 10/1/2016
Readmission Rates 1/1/2017 10/1/2016 10/1/2016 10/1/2016

Risk Adjustment of Measures

The Secretary will adjust the quality measures and resource use to account for clinical risk factors (e.g., age, co-morbid conditions, severity of illness), as the Secretary deems appropriate. Accounting for patients' risk factors is intended to facilitate more accurate comparison of statistics, such as the hospitalization rate of PAC patients, furthering the Act's purpose of providing standardized and interoperable PAC assessment data.

Consensus-Based Entity to Endorse Measures

Quality measures and resource use and other measures reported by PAC providers must be endorsed by a consensus-based entity with a contract under section 1890(a) of the Social Security Act (SSA), such as the National Quality Forum.6

PAC Providers That Fail to Report Will Be Subject to a Reduction in Market Basket Prices

Beginning with the specified dates listed in Table 1 and Table 2 above, HHAs, IRFs, LTCHs, and SNFs that fail to report quality measures and resource use and other measures will be subject to a two percentage point reduction in market basket prices in effect under the existing provisions of the SSA.7 Similarly, beginning in 20198, HHAs, IRFs, and LTCHs that do not provide the required patient assessment data will be subject to the same two percentage point reduction under the SSA. Additionally, beginning with the fiscal year 2018, for SNFs that do not provide patient assessment data, the Secretary will reduce the SNF's market basket update by the same two percentage points. The reduction in percentage may result in a market basket update of less than zero. Any reduction is limited to that fiscal year, thus, reductions are not cumulative.

Utilizing Quality Measures and Resource Use Measures in Discharge Planning

The Secretary must promulgate regulations by January 1, 2016 that will require PAC providers to take certain factors into account in the discharge planning process: (1) quality measures; (2) resource use measures; and (3) other measures under the applicable reporting provisions. Specifically, these regulations and interpretive guidance will address the settings to which a patient may be discharged in order to aid the transition for the beneficiary. The regulations and interpretive guidance will also address the treatment preferences of patients; and the goals of care of patients.

PROVIDER FEEDBACK STAGE

Beginning one year after the dates that PAC providers must begin reporting quality measures and resource use measures, the Secretary will provide confidential feedback reports to the PAC providers on their performance regarding these measures.9 If possible, the Secretary will provide these confidential feedback reports at least on a quarterly basis. If the PAC providers report measures on an annual basis, the Secretary may provide them confidential feedback reports annually.

Table 3: Timeline for Feedback Reports on Quality Measures
Quality Domains HHAs SNFs IRFs LTCHs
Functional Status 1/1/2020 10/1/2017 10/1/2017 10/1/2019
Skin Integrity 1/1/2018 10/1/2017 10/1/2017 10/1/2017
Medication Reconciliation 1/1/2018 10/1/2019 10/1/2019 10/1/2019
Major Falls 1/1/2020 10/1/2017 10/1/2017 10/1/2017
Patient Health Information and Preference 1/1/2020 10/1/2019 10/1/2019 10/1/2019


Table 4: Timeline for Feedback Reports on Resource Measures
Resource Use Measures HHAs SNFs IRFs LTCHs
Resource Use Measures 1/1/2018 10/1/2017 10/1/2017 10/1/2017
Discharge to Community 1/1/2018 10/1/2017 10/1/2017 10/1/2017
Readmission Rates 1/1/2018 10/1/2017 10/1/2017 10/1/2017

PUBLIC REPORTING STAGE

The Secretary will then create procedures for making public the information regarding performance under the measures. Under these procedures, a PAC provider will have the opportunity to review and submit corrections to the data and information before it is made public. The information must be made public beginning no later than two years after the dates that PAC providers must begin reporting quality measures and resource use measures.10

Table 5: Timeline for Public Reports on Quality Measures
Quality Measures HHAs SNFs IRFs LTCHs
Functional Status 1/1/2021 10/1/2018 10/1/2018 10/1/2020
Skin Integrity 1/1/2019 10/1/2018 10/1/2018 10/1/2018
Medication Reconciliation 1/1/2019 10/1/2020 10/1/2020 10/1/2020
Major Falls 1/1/2021 10/1/2018 10/1/2018 10/1/2018
Patient Health Information and Preference 1/1/2021 10/1/2020 10/1/2020 10/1/2020


Table 6: Timeline for Public Reports on Resource Measures
Resource Use Measures HHAs SNFs IRFs LTCHs
Resource Use Measures 1/1/2019 10/1/2018 10/1/2018 10/1/2018
Discharge to Community 1/1/2019 10/1/2018 10/1/2018 10/1/2018
Readmission Rates 1/1/2019 10/1/2018 10/1/2018 10/1/2018

CONGRESSIONAL REPORTING STAGE

The First MedPAC Report

MedPAC must submit a report to Congress regarding alternative models for a PAC provider payment system. MedPAC is required to evaluate and recommend features of future PAC payment systems that establish, or a unified payment system that establishes, payment rates according to individuals' characteristics instead of the PAC setting in which individuals are treated. This report will be submitted no later than June 30, 2016.

Secretary's Report

In consultation with MedPAC and appropriate stakeholders, the Secretary will submit a report to Congress regarding alternative models for a PAC provider payment system. The report will include:

  • Recommendations on and a technical prototype of a PAC prospective payment system that would—

    • Base payments on individual characteristics of the patient as opposed to the PAC setting
    • Account for clinical appropriateness of items and services provided and the beneficiary outcomes
    • Incorporate standardized patient assessment data received under prior sections of the IMPACT Act
    • Further clinical integration
  • Recommendations on which Medicare fee-for-service regulations for PAC payment systems should be altered.
  • An analysis of the impact of the recommended payment system on beneficiary cost-sharing, access to care, and choice of setting.
  • A projection of any potential reduction in expenditures that may be attributable to the application of the recommended payment system.
  • A review of the value of subsection (d) hospitals collecting and reporting to the Secretary standardized patient assessment data for inpatient hospital services furnished by such a hospital to Medicare beneficiaries.

This report will be submitted no later than two years after the Secretary has collected two years of data on quality measures.

The Second MedPAC Report

No later than the first June 30 following the Secretary's report, MedPAC will submit a report to Congress, including recommendations and a technical prototype for a PAC prospective payment system that would satisfy the criteria required of the prototype submitted in the Secretary's report.

HHS to Conduct Studies Concerning the Impact that Individuals' Socioeconomic Status, Race, and Other Factors Have Upon Quality and Resource Use

Not more than two years after the date of the IMPACT Act's enactment, the Secretary is required to study (and report to Congress) the effect of individuals' socioeconomic status on quality measures and resource use and other measures. Not more than five years after the date of the IMPACT Act's enactment, the Secretary will submit a report on a study to Congress regarding the impact of risk factors (such as race, health literacy, limited English proficiency, and Medicare beneficiary activity on quality measures and resource use and other measures).

CHANGES TO HOSPICE SURVEY AND MEDICAL REVIEW REQUIREMENTS

Survey Requirement

All Medicare-certified hospice programs will be subject to more frequent surveys: no less frequently than once every 36 months, beginning in April 2015 and ending September 30, 2025. The surveys may be administered by an appropriate state or local survey agency, or an approved accreditation agency, as determined by the Secretary.

Medical Review of Certain Hospice Care

For PAC providers certified as hospice programs, the Act changes the trigger for medical review of certain patients' care. The Affordable Care Act required medical review of hospice stays exceeding 180 days for hospices with an unusually large share of long-stay patients. Under the IMPACT Act, medical review takes place if the number of cases of patients receiving more than 180 days of care exceeds a percent of the total number of all cases of individuals cared for by the hospice at issue. This means that the trigger for such medical review of patients' hospice care will be tailored to each individual hospice program.

Hospice Payment Cap

The Act also aligns hospice reimbursement and the hospice aggregate financial cap to a common inflationary index.

CONCLUSION

The IMPACT Act imposes several new requirements upon PAC providers in the coming years, and may have a significant effect on the manner in which Congress addresses the question of how to modify the PAC prospective payment systems.

Through its rule-making procedures, CMS is granted significant authority to design and implement the new data collection and reporting systems, each of which has the potential to present challenges to PAC providers. Stakeholders, such as the American Hospital Association, have already questioned whether the new quality measures will be consistent with existing patient assessment measures, and whether providers will face the challenge of submitting multiple sets of distinct but similar measures. Before the initial rulemaking to implement the IMPACT Act, the Secretary must allow for stakeholder input—for example, through town halls, open door forums, and mail-box submissions. This is one way—in addition to notice-and-comment rulemaking—for PAC providers to be involved in the Act's implementation.

Footnotes

1. H.R. 4994, 113th Cong. (2nd Sess. 2014).

2. See e.g. Post-Acute Care Payment Reform Demonstration Final Report (March 2012) (available here: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Research-Reports-Items/PAC_Payment_Reform_Demo_Final.html); see also Post-Acute Care Providers: Steps toward Broad Payment Reforms, MedPAC Report to Congress (March 2014) (available here: http://www.medpac.gov/documents/reports/chapter-7-post-acute-care-providers-steps-toward-broad-payment-reforms-(march-2014-report).pdf?sfvrsn=2).

3. The Secretary must modify the PAC assessment instruments as necessary to enable their use for the purposes required by the Act; however, changes may not occur more than once per calendar or fiscal year, unless the Secretary publishes a justification for the modification in the Federal Register.

4. See 42 C.F.R. § 484.55; see also id. § 484.250.

5. See 42 U.S.C. § 1395i-3(b)(3)(A).

6. 42 U.S.C. § 1395aaa(a). Under section 1890(a), consensus-based entities endorse measures by considering whether a measure is: "(A) evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics (i.e. health status, language capabilities, race or ethnicity, and income level); and, (B) consistent across types of health care providers, including hospitals and physicians."

7. For HHAs, see 42 U.S.C. § 1395fff(b)(3)(B)(v). For IRFs, see 42 U.S.C. § 1395ww(j)(7). For LTCHs, see 42 U.S.C. § 1395ww(m)(5).

8. For HHAs, the applicable date is the calendar year 2019. For IRFs, the applicable date is fiscal year 2019. For LTCHs, the applicable date is the rate year 2019.

9. See Table 3 for summary of feedback report deadlines for quality measures. See Table 4 for summary of feedback report deadlines for resource use measures.

10. See Tables 5 and 6 for the respective public reporting deadlines.

This article is presented for informational purposes only and is not intended to constitute legal advice.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
 
In association with
Related Topics
 
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions