Public Reporting: Provider Preview Report and Requests for CMS Review of Data

Provider Preview Report (Hospice Item Set (HIS) and Medicare claims-based measures)

Before each quarterly release of data on Care Compare, hospice providers may review their quality measure results during a 30-day preview period using the Provider Preview Report. The purpose of this report is to allow providers the opportunity to preview each of their HIS and claims-based quality measure results, before public display on Care Compare. Provider Preview Reports are accessible via the Certification and Survey Provider Enhanced Reports (CASPER) application, which is accessible from a Hospice’s “Welcome to the CMS QIES Systems for Providers” page.

 Note: Once released, providers will have 30 days during which to review their quality measure results. Although the actual “preview period” is 30 days, the reports will continue to be available for another 30 days, or a total of 60 days. The Centers for Medicare & Medicaid Services (CMS) encourages providers to download and save their Hospice Provider Preview Reports for future reference, as they will no longer be available in CASPER after this 60-day period.

Instructions on how to access the reports are available in the Downloads section below.

Special Note about the COVID-19 Public Health Emergency (PHE): Due to the temporary exemption to the HQRP data submission requirements in response to the (coronavirus disease of 2019) COVID-19 PHE, public reporting of hospices’ data was frozen after the November 2020 refresh. This means that since the November 2020 refresh, CMS has been holding the publicly reported data constant through the November 2021 refresh. Further, CMS has not been issuing Provider Preview Reports for those refreshes that continue to display constant or frozen data. CMS will resume public reporting and Provider Preview Reports with the February 2022 refresh. For additional information, please refer to the FY 2022 Hospice Final Rule on the Hospice Center page.

Thirty-Day Preview Period

Hospices will have 30 days to preview their HIS and claims-based quality measure results, beginning on the date that CMS issues the reports. Should the hospice provider believe the denominator or another quality metric to be inaccurate, a provider may request a CMS review of the calculations contained within the Provider Preview Report.

Note:  CMS does not consider inaccurate data related to provider submission errors as a reason to review HIS or claims data. CMS also does not consider data to be “inaccurate” because a provider did not make necessary corrections to the HIS data prior to the Data Correction Deadline or corrections to claims data before CMS extracts them for measure calculation (this occurs at least 90 days after the last discharge date in the reporting period). CMS will consider a measure score as accurately based on the HIS and claims data that were in our system at the time the quality measure was calculated. CMS encourages providers to review and correct their HIS data before the Data Submission Deadline, and to submit accurate and timely claims.

To request a CMS review, hospices must follow the process outlined under Procedures for Requesting CMS’ Review of data during the Preview Period, as described below.

Questions related to public reporting, other than requests for a CMS review, should be directed to the Hospice Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov.

Per the CMS Hospice Quality Reporting Program (HQRP) policy, hospice providers can continue to make changes to their patient-level HIS data for up to 24 months beyond the target date on any given HIS assessment. However, any modifications made to HIS data on or after the Hospice Provider Preview Report Data Correction Deadline will only be reflected in subsequent Provider Preview Reports and Care Compare refreshes. These changes will not affect the current Provider Preview Report or the related Care Compare Refresh. CMS encourages providers to review the Hospice Public Reporting Key Dates table on the HQRP Public Reporting: Key Dates for Providers webpage.

Procedures for Requesting CMS’ Review of data during the Preview Period:

CMS encourages providers to review the data provided in their hospices’ Provider Preview Reports. If a provider disagrees with the quality measure results (denominator or another quality metric) contained within their report, they have an opportunity to request a review of the calculations by CMS. To make a request, providers must adhere to the process outlined below:

• Submit requests during the 30-day preview period.
  • The 30-day period begins on the day the Provider Preview Reports are available in Hospice CASPER folders through 11:59:59 p.m. PST on day 30th of the preview period.
  • NOTE: CMS will not accept any requests for review of measure results that are submitted after the posted deadline, which falls on the last day of the preview period.
• Submit requests to CMS via email:
  • Subject line should include:
    • “[Provider Name] Hospice Public Reporting Request for Review of Measure Results.”
    • The Hospice CMS Certification Number (CCN)

Subject line example: St. Mary’s Hospice and Home Care, Hospice Public Reporting Request for Review of Measure Results, XXXXXX.

• Send to the following email address: HospicePRquestions@cms.hhs.gov.
  • Please note: The only method for submitting a request to CMS for review of your Preview Report data is via email to: HospicePRquestions@cms.hhs.gov.
• MUST include ALL of the following information:
  • Hospice CMS Certification Number (CCN)
  • Hospice Agency Name and Mailing Address
  • CEO or CEO-designated representative contact information. Include:
    • name, email address, telephone number, and physical mailing address
  • Supporting Information:
  • Support the belief that the data contained within your hospice’s Preview Report is erroneous, including, but not limited to, all HIS or claims-based quality measures affected, and aspects of quality measures affected (e.g., denominator or quality metric)

Requests that include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations or those submitted by any other means will NOT be reviewed by CMS.

• An email confirmation receipt will be sent to the contact person named above.
• Providers may receive a request for additional information to enable CMS to fully evaluate the issue.
• Please note: Due to the COVID-PHE, CMS determined that they would not publicly report quality measures based on Q1 and Q2 2020 data; therefore, data correction for these quarters is not necessary for public reporting.
• For information about Key dates, visit the Public Reporting: Key Dates for Providers webpage.