Hospice Quality Reporting Program Update: CMS Issues HIS Timeliness Compliance Threshold Report 

Situation Report | September 27, 2021 

The U.S. Centers for Medicare and Medicaid (CMS) recently announced that Medicare certified hospices can now access their confidential Quality Measure (QM) reports in CASPER for two new publicly reported measures: Hospice Care Index (HCI) and Hospice Visits in the Last Days of Life (HVLDL).  

These two claims-based measures will be publicly reported on Care Compare no sooner than May 2022. 

Hospices have been anxiously waiting to see these reports as no national performance data on either measure has been available for hospices to use for benchmarking. Hospices must rely solely on CMS’s calculations of the HCI because hospital claims data is used for some of the indicators comprising this Index and hospices do not have access to this data. 

According to the CMS notice about the QM reports being available, claims from fiscal years 2018 and 2019 were used to calculate the measures. The CASPER Report User’s Guide is available here and has been updated to include the new reports. 

In addition to the QM reports now being available, the Timeliness Compliance Threshold for HIS Submissions: Fact Sheet has been updated and is available here.

This fact sheet outlines the timeliness compliance threshold for HIS (Hospice Item Set) submissions, details the algorithm for calculation and explains the associated CASPER report.  

It is especially prudent for hospices to view their Timeliness Compliance Threshold report because the annual payment update penalty of two percent that is applicable to hospices that have not complied with the HIS and/or CAHPS Hospice Survey submission requirements increases to four percent effective with the Fiscal Year (FY) 2024 payment year.