Public Reporting: Consumer Assessment of Healthcare Providers & Systems (CAHPS) Preview Reports and Requests for CMS Review of CAHPS Data

Hospice CAHPS® Survey Provider Preview Reports

Prior to each quarterly release of data on Care Compare, hospice providers are given the opportunity to review their Hospice Consumer Assessment of Healthcare Providers & System (CAHPS®) results during a 30-day preview period using the Hospice CAHPS® Provider Preview Report. The purpose of these reports is to give providers the opportunity to preview their Hospice CAHPS® survey results on each measure prior to public display on Care Compare. Hospice CAHPS® Provider Preview Reports can be accessed 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. 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: Due to the temporary exemption to the Hospice Quality Reporting Program (HQRP) data submission requirements in responding to the coronavirus disease of 2019 (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 CAHPS® Preview Period

Hospices will have 30 days to preview their Hospice CAHPS® Survey measure results beginning on the date the reports are made available by CMS. Should the hospice provider believe the data is inaccurate, a provider may request a CMS review of the data contained within the CAHPS® Provider Preview Report.

The data presented in the CAHPS® Provider Preview Report is case-mix adjusted. This means it may not match the data you may be receiving from your vendor. A mismatch of this type does not imply the data in the Preview Report is inaccurate.

Requests for review of your Hospice CAHPS® Survey results must be submitted via email to hospicecahpssurvey@hsag.com. Please note this is a different address than the one used for review requests involving HIS data.

All other questions related to the Hospice Quality Reporting Program should be directed to the Hospice Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov. Technical questions about the Hospice CAHPS® Survey should be directed to hospicecahpssurvey@hsag.com, or call toll-free at 1-844-472-4621.

Procedures for Requesting CMS’ Review of Hospice CAHPS® Survey data during Preview Period:

CAHPS Preview Reports and Requests for CMS Review of CAHPS® Data

We encourage Hospice Providers to review their Hospice CAHPS® Survey data. If a provider believes their results are in error, they will have an opportunity to request a 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 Hospice CAHPS® Survey 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 Hospice CAHPS® Survey 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 Hospice CAHPS® Survey Results, XXXXXX). The request must be sent to the following email address: hospicecahpssurvey@hsag.com.
• 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 CAHPS® Preview Report is erroneous.
• 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. Review requests must be submitted within 30 days of the opening of the preview period to be considered.

Please note: The only method for submitting a request to CMS for review of your CAHPS® Preview Report data is via email hospicecahpssurvey@hsag.com. 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.

Hospice Quality Reporting Program Archives