Public Reporting: Key Dates for Providers

Public Reporting: Key Dates for Providers

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.

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

CMS Hospice Public Reporting Key Dates for Providers

CMS encourages providers to be familiar with the important dates outlined in the tables below. Providers need to submit all Hospice Item Set (HIS) modification or inactivation records prior to the 4.5 month data correction deadline for public reporting for the modifications to be reflected in the corresponding HIS Provider Preview Report and public display, located on Care Compare.

This means that providers have 4.5 months following the end of each calendar year (CY) quarter to review and correct their HIS records with target dates (which is the admission date for HIS-Admission records and discharge date for HIS-Discharge records) in that quarter for public reporting. After this 4.5 month data correction deadline has passed, HIS data from that calendar quarter will be permanently frozen for the purposes of public reporting. Updates made after the correction deadline will not appear in any subsequent Care Compare refresh. This policy is at the HIS record-level, meaning a patient’s HIS-Admission and HIS-Discharge records may have different data correction deadlines.

Care Compare Refresh Schedule and Preview Periods

Refresh DateNovember 2024 RefreshFebruary 2025 RefreshMay 2025 RefreshAugust 2025 Refresh
Quarters Included in Refresh for HIS Measures (includes patients discharged during these quarters)Quarter 1 2023 – Quarter 4 2023Quarter 2 2023 – Quarter 1 2024Quarter 3 2023 – Quarter 2 2024Quarter 4 2023 – Quarter 3 2024
Quarters included in Refresh for CAHPS measure scores (includes patients who died during these quarters)Quarter 1 2022 – Quarter 4 2023Quarter 2 2022 – Quarter 1 2024Quarter 3 2022 – Quarter 2 2024Quarter 4 2022 – Quarter 3 2024
Quarters included in Refresh for CAHPS Star Ratings (includes patients who died during these quarters)Quarter 4 2021 – Quarter 3 2023Quarter 2 2022 – Quarter 1 2024Quarter 2 2022 – Quarter 1 2024Quarter 4 2022 – Quarter 3 2024
Quarters included in Refresh for Claims-based Measures (includes patients with claims for care received during these quarters)Quarter 1 2022 – Quarter 4 2023Quarter 1 2022 – Quarter 4 2023Quarter 1 2022 – Quarter 4 2023Quarter 1 2022 – Quarter 4 2023
Month that Provider Preview Reports (HIS, Claims, CAHPS) are releasedAugustNovemberFebruaryMay

 

Upcoming Data Correction Deadlines for Public Reporting

Target Date of HIS RecordHIS Record Data Correction Deadline for Public Reporting (11:59:59 p.m. E.T.)
Quarter 2, 2024(04/01/24-06/30/24)November 15, 2024
Quarter 3, 2024(07/01/24-09/30/24)February 17, 2025
Quarter 4, 2024(10/01/24-12/31/24)May 15, 2025
Quarter 1, 2025(01/01/25-03/31/25)August 15, 2025

CMS encourages providers to review quality measure data early and often using their CASPER QM Reports and not wait until the 4.5-month data correction deadline for public reporting to submit any necessary HIS corrections. For more information on how providers can use their CASPER QM Reports to review data please see the CASPER QM Reports Fact Sheet in the Downloads section of the HQRP Requirements and Best Practices webpage.

Upcoming CAHPS Hospice Survey Data Submission Deadlines

During CY 2024 and 2025, the CAHPS Hospice Survey will continue data collection as normal.  This means that deadlines for data submission to the CAHPS Hospice Survey data warehouse will occur on the second Wednesday of the month in February, May, August, and November.

CAHPS Hospice Survey Upcoming Data Submission Deadlines in CY 2024 and 2025

Quarter Dates of DeathData Submission Deadline
Quarter 2 2024April-June 2024November 13, 2024
Quarter 3 2024July-September 2024February 12, 2025
Quarter 4 2024October-December 2024May 14, 2025
Quarter 1 2025January-March 2025August 13, 2025

 

Page Last Modified:
01/16/2025 10:34 AM