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

Provider Preview Report 

Before each quarterly release of data on the Compare tool on Medicare.gov, 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 their results from patient-level data collected via the Hospice Outcomes and Patient Evaluation (HOPE) or the Hospice Item Set (HIS), and claims-based quality measure results, before public display on the Compare tool. Provider Preview Reports are accessible via the Internet Quality Improvement and Evaluation System (iQIES).

 Note: Once released, providers have 30 days to review their quality measure results. Although the actual “preview period” is 30 days, the reports remain 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 are not available in iQIES after this 60-day period.

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

Thirty-Day Preview Period

Hospices have 30 days to preview results based on their patient-level data collected via HOPE (or 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 is inaccurate, the 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 HOPE (or HIS), or claims data. CMS also does not consider data to be “inaccurate” because a provider did not make necessary corrections to the patient-level 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 considers a measure score accurate when based on the patient-level data HOPE (or 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 HOPE (or 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.

Data Correction Policy

Per the HQRP policy, providers may make changes to their patient-level HOPE data for up to 24 months after the target date on any given HOPE record. However, any modifications submitted on or after the Hospice Provider Preview Report Data Correction Deadline are only reflected in subsequent Provider Preview Reports and the Compare tool refreshes. These changes will not affect the current Provider Preview Report or its associated Compare tool 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 may 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 the iQIES folders through 11:59:59 p.m. PST on day 30 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, [Insert 6 digit CCN].

• 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.
• Request 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 HOPE, 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.
• For information about Key dates, visit the Public Reporting: Key Dates for Providers webpage.