Public Reporting: HIS Preview Reports and Requests for CMS Review of HIS Data
HIS Provider Preview Reports
Before each quarterly release of data on Care Compare, which has replaced Hospice Compare, hospice providers will review their HIS quality measure results during a 30-day preview period using the HIS Provider Preview Report. The purpose of these reports is to give providers the opportunity to preview their quality measure results on each quality measure before public display on Care Compare. HIS 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.
Please note: Providers will not be able to access their preview reports after 60 days from the report release date. 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 Download section below.
Special Note: Due to the temporary exemption to the HQRP data submission requirements in responding to the COVID-19 Public Health Emergency (PHE), public reporting of hospices’ data will freeze after the November 2020 refresh. This means that following the November 2020 refresh, CMS will hold the publicly reported data constant through the November 2021 refresh. Further, CMS will not issue Provider Preview Reports for those refreshes that continue to display the constant or frozen data. For additional information on COVID-19 PHE data exemption, please see the Hospice COVID-19 Public Reporting Tip Sheet (PDF) in the Downloads section of the HQRP Requirements and Best Practices webpage.
Thirty Day HIS Preview Period
Hospices will have 30 days to preview their HIS quality measure results beginning on the date that CMS makes the reports available. Should the hospice provider believe the denominator or other quality metric to be inaccurate, a provider may request a CMS review of the calculations contained within the HIS Provider Preview Report.
Please note CMS does not consider inaccurate data related to provider submission error a reason to review HIS data. CMS does not consider data to be “inaccurate” because a provider did not make necessary corrections to the HIS data prior to a specific “freeze date,” as the measure score is accurate based on the data that was in our system at the time the quality measure was calculated.
Hospices must make requests for CMS review of HIS data during the 30-day preview period and submit the request to HospicePRquestions@cms.hhs.gov. The request must contain all of the required information as listed below, under Procedures for Requesting CMS’ Review of HIS data during the Preview Period.
Hospices should direct all questions related to HIS public reporting, other than requests for CMS review, should be directed to the Hospice Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov.
Hospice providers, per the CMS Hospice QRP policy, 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 freeze date, will only be reflected in subsequent Provider Preview Reports and Care Compare refreshes. These changes will not affect the current HIS Provider Preview Report or the related Care Compare Refresh. CMS encourages providers to review the Hospice Public Reporting Key Dates table on the Hospice Quality Public Reporting: Key Dates for Providers webpage.
Procedures for Requesting CMS’ Review of HIS data during Preview Period:
We encourage Hospice Providers to review their data provided in the HIS Provider Preview Reports. If a provider disagrees with their quality measure results (denominator or quality metric) contained within their HIS Provider Preview Report, they have an opportunity to request review of the calculations by CMS. To make a request, providers must adhere to the process outlined below:
- Requests for CMS review of measure results may be submitted to CMS beginning on the day the HIS Provider Preview Reports are available in Hospice CASPER folders through 11:59:59 p.m. PST on day 30 of the preview period.
- 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.
- Hospices are required to submit their request to CMS via email with the subject line: “[Provider Name] Hospice Public Reporting Request for Review of HIS Measure Results” and include the Hospice CMS Certification Number (CCN) (e.g., St. Mary’s Hospice and Home Care, Hospice Public Reporting Request for Review of HIS Measure Results, XXXXXX). Requests must be sent to the following email address: HospicePRquestions@cms.hhs.gov.
- Email request must include the following information:
- Hospice CMS Certification Number (CCN)
- Hospice Agency Name and Mailing Address
- CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
- Information supporting the Hospice’s belief that the data contained within their Preview Report is erroneous, including, but not limited to, all HIS quality measures affected, and aspects of quality measures affected (denominator or quality metric)
- Hospices will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.
- CMS will review all requests and provide responses via email. Please note that any corrections to underlying data that are made on or after the Hospice Provider Preview Report freeze date, will not affect the current Hospice Provider Preview Report or the related Care Compare Refresh and only be reflected in subsequent quarterly Preview Report and Care Compare refresh.
- Please note that due to the COVID-PHE, CMS indicated that data submission for Q1 2020 and Q2 2020 was exempted and would not be publicly reported; therefore the data correction for the two exempted quarters is not necessary. Further, public reporting of hospices’ data will freeze after the November 2020 refresh. This means that following the November 2020 refresh, CMS will hold the publicly reported data constant through the November 2021 refresh. Additionally, CMS will not issue Provider Preview Reports for those refreshes that continue to display the constant or frozen data. For additional information on COVID-19 PHE data exemption, please see the Hospice COVID-19 Public Reporting Tip Sheet (PDF) in the Downloads section of the HQRP Requirements and Best Practices webpage.
- Hospices can still submit HIS modification and inactive records for up to 24 months after the target date; however, the corrections submitted after the Hospice Provider Preview report freeze date will not be reflected until the next Preview Report is generated.
- For details on dates: see the Hospice Public Reporting Key Dates table on the Public Reporting: Key Dates for Providers webpage.
Please note: The only method for submitting a request to CMS for review of your HIS Preview Report data is via email (HospicePRquestions@cms.hhs.gov). Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations in the request being submitted to CMS for review.