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Public Reporting: HIS Preview Reports and Requests for CMS Review of HIS Data

HIS Provider Preview Reports

Prior to each quarterly release of data on Hospice Compare, hospice providers are given the opportunity to review their HIS quality measure results during a 30-day preview period using a 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 prior to public display on Hospice Compare. HIS Provider Preview Reports can be accessed via 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.

Thirty Day HIS Preview Period

Hospices will have 30 days to preview their HIS quality measure results beginning on the date the reports are made available by CMS. Should the hospice provider believe the denominator or other quality metric to be inaccurate, a provider may request CMS review of the calculations contained within the HIS Provider Preview Report.

Please note that inaccurate data related to provider submission errors will not be considered a reason for CMS review of 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. All requests for CMS review of HIS data must be made during the 30-day preview period. All requests for CMS review of the HIS-based measure calculations must be submitted to HospicePRquestions@cms.hhs.gov, and must contain all required information, as listed below.

 

Requests for CMS review of your Hospice CAHPS® Survey results must be submitted via email to: hospicecahpssurvey@HCQIS.org. Please note this is a different address than the one used for review requests involving HIS data. Details of this request process can be found on the Hospice Quality Public Reporting: CAHPS Preview Reports and Requests for CMS Review of CAHPS Data  webpage.

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.

Although Hospice providers, per the CMS Hospice QRP policy, can continue to make changes to their patient-level HIS data for up to 36 months beyond the target date on any given HIS assessment, any modifications that are made to underlying HIS data on or after the Hospice Provider Preview Report freeze date, will not affect the current HIS Provider Preview Report or the related Hospice Compare Refresh and only be reflected in subsequent preview reports and Compare refreshes. CMS encourages providers to the review the Hospice Public Reporting Key Dates table on the Hospice Quality Public Reporting: Key Dates for Providers .

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

We encourage Hospice Providers to review their data as 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 will have an opportunity to request review of the calculations by CMS. In order to make such a request, providers must adhere to the process outlined below:

  • Requests for CMS review of measure results be submitted to CMS beginning on the day the HIS Provider Preview Reports are available in Hospice CASPER folders, and may be submitted 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). The request must be sent to the following email address: HospicePRquestions@cms.hhs.gov.
  • The 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 outlining our decisions 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 Hospice Compare Refresh and only be reflected in subsequent quarterly Preview Report and Hospice Compare refresh.
  • The data used to generate the Hospice Provider Preview Reports are frozen for the upcoming Hospice Compare refresh, and corrections submitted after Hospice Provider Preview Report freeze date (see Hospice Public Reporting Key Dates table on the Hospice Quality Public Reporting: Key Dates for Providers tab ) will not be reflected until the next Preview Report is generated (next quarter). However, Hospices can still submit HIS modification and inactivation records for up to 36 months after the target date.

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.

 

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