Hospice Claims-Based Reporting Outline for HQRP and Quality Measures

Home
Hospice
Hospice Claims-Based Reporting Outline for HQRP and Quality Measures

Hospice Claims-Based Reporting Outline for HQRP and Quality Measures

Hospice leaders feel the pressure of quality reporting most acutely when the numbers no longer look like abstract policy. A low score for visits in the final days of life or a change in the Hospice Care Index can trigger difficult board conversations, contract reviews, and questions from families who found the data on Medicare’s Care Compare. Behind those public scores is a complex mix of assessment tools, surveys, and claims-based measures.

In the Hospice Quality Reporting Program (HQRP), claims-based measures can be easy to overlook because they do not require a separate submission workflow. They are calculated from the Medicare claims you already send. Yet those same claims drive publicly reported quality scores and can affect your reputation in your market. As CMS transitions from the Hospice Item Set (HIS) to the new Hospice Outcomes and Patient Evaluation (HOPE) tool beginning October 1, 2025, the role of claims-based reporting in painting a complete picture of hospice quality will become even more visible.

This article outlines how claims-based measures fit into HQRP, what they actually capture, and how hospices can build reliable internal processes so the data that flow through your billing system truly reflect the care you provide.

How Claims-Based Measures Fit Into the Hospice Quality Reporting Program

CMS built the Hospice Quality Reporting Program under Section 1814(i)(5) of the Social Security Act to give the public a standardized view of hospice quality based on multiple data sources. Today, HQRP includes assessment data from HIS (and HOPE after implementation), the CAHPS Hospice Survey, and a defined set of claims-based measures derived from Medicare fee-for-service claims.

CMS describes HQRP as a pay-for-reporting system. For now, compliance is tied to whether hospices submit and maintain complete, timely data for the program’s components, not to the actual performance scores. Hospices that do not comply face a 4 percent reduction to the Annual Payment Update for the applicable fiscal year, an increase from the prior 2 percent penalty that applies beginning with the FY 2024 APU and each year thereafter (CMS HQRP overview). Hospice providers who do not meet reporting deadlines may face a 4 percent reduction in their annual market basket update, effectively reducing reimbursement for the following fiscal year.

For claims-based measures, there is no separate data feed. CMS uses the hospice claims already in its systems as of the designated measurement periods. These claims-based measures are then combined with assessment and survey data to produce the quality scores displayed on Medicare’s Care Compare site and in the Provider Data Catalog (CMS public reporting background). Hospices must meet or exceed data submission thresholds set at 90 percent of all required HIS or successor instrument records within 30 days of the beneficiary’s admission or discharge.

That structure creates an important operational reality. Every hospice claim you submit has a dual role. It supports payment and, over time, contributes to quality scores that patients, referral partners, payers, and regulators can see.

Core Hospice Claims-Based Quality Measures

At present, HQRP focuses on two primary claims-based hospice quality measures. CMS and educational partners consistently reference these measures as the core claims-based elements within HQRP: the Hospice Visits in the Last Days of Life and the Hospice Care Index (CMS HQRP overview, MedBridge HQRP explainer).

The Hospice Visits in the Last Days of Life (HVLDL) measure looks at the percentage of hospice patients who receive visits from hospice clinical staff in the final days of life. The exact specifications are technical, but at a practical level this measure asks whether your team is at the bedside, either physically or through telehealth, when patients and families need you most.

The Hospice Care Index (HCI) is a composite measure that aggregates several indicators of care patterns into a single index. Among other factors, it considers visit frequency, transitions such as live discharges and hospice revocations, and other utilization markers that can signal fragmentation or instability in care. Because it is composite, the HCI gives a broader view of how consistently a hospice delivers care that is aligned with program expectations.

Both measures are calculated solely from Medicare claims. There is no supplemental data portal and no opportunity to “self-report” corrections once CMS has extracted the claims for a given reporting period. That makes internal billing discipline central to quality reporting, not just to cash flow.

Medicare and Medicaid Services: Regulatory Context for Claims-Based Reporting

The Centers for Medicare & Medicaid Services (CMS) set the regulatory foundation for hospice quality reporting, shaping how healthcare providers deliver, document, and demonstrate the value of hospice care. Through the Hospice Quality Reporting Program (HQRP), CMS requires Medicare certified hospice providers to submit data that reflect both the quality and consistency of their hospice services. This regulatory framework is designed to ensure that hospices meet rigorous standards for patient evaluation, hospice outcomes, and public accountability.

A central pillar of HQRP is the data submission compliance threshold. Hospices must submit at least 90% of required data elements for each reporting period to avoid a reduction in their annual payment update. This threshold applies to all core reporting requirements, including the Hospice Item Set (HIS), the CAHPS Hospice Survey, and Medicare claims data used to calculate quality measures such as the Hospice Care Index (HCI) and Hospice Visits in the Last Days of Life (HVLDL). Failing to meet these data completion thresholds can result in a 4% reduction to the annual payment update, directly impacting provider reimbursement and financial performance.

To comply with HQRP, hospices must also adhere to minimum business requirements. These include being in operation for at least four years and conducting surveys using an approved survey mode for a minimum of three years. Survey administration processes must be managed by qualified survey vendors—organizations that are independent from the hospice and do not use home-based or virtual interviewers. This ensures the integrity of hospice survey data and prevents conflicts of interest. Hospices are prohibited from administering their own CAHPS Hospice Survey or acting as a survey vendor for any hospice, further safeguarding the objectivity of quality reporting.

When a hospice is unable to meet the data submission threshold due to extraordinary circumstances—such as natural disasters or public health emergencies—CMS provides a process for requesting exemptions or extensions. Hospices must submit a formal request within 90 days of the date identified for the extraordinary event, including their CMS certification number, business name, physical address, contact information, and a detailed explanation of the impact and proposed date for resuming data submission. CMS may also grant exemptions proactively if an event affects an entire region or locale. These provisions ensure that hospices are not unfairly penalized for circumstances beyond their control, while maintaining the integrity of the quality reporting program.

If a hospice disagrees with a CMS decision regarding HQRP compliance or data submission, it may submit a reconsideration request following the requirements outlined on the CMS Hospice Quality Reporting website. This request must be filed within 30 days of the notification date. Should the hospice remain dissatisfied after reconsideration, it has the right to appeal to the Provider Reimbursement Review Board under the relevant federal regulations.

Beyond HQRP, the Medicare Hospice Benefit (MHB) mandates that hospices submit claims containing data elements that enable CMS and policymakers to assess hospice quality. The MHB includes ten quality indicators—ranging from service provision to live discharge patterns—calculated using 100% Medicare fee-for-service claims. These indicators, along with composite measures like the Hospice Care Index, provide a comprehensive view of hospice visits, symptom management, and patient evaluation throughout the hospice stay. By analyzing this administrative data, CMS and healthcare providers can benchmark performance, identify trends, and drive continuous quality improvement.

In summary, the regulatory context for claims-based reporting in hospice care is both comprehensive and evolving. Adhering to HQRP requirements, meeting data submission compliance thresholds, and understanding the processes for reconsideration and exemption are essential for maintaining Medicare certification and ensuring high-quality hospice care. By leveraging Medicare claims data, quality measures, and survey data, hospices can capture the full scope of services provided, support public reporting, and contribute to a culture of accountability and excellence in end-of-life care.

The Mechanics of Claims-Based Measurement

The way CMS constructs claims-based measures in hospice parallels its approach in home health and other post-acute settings. In home health, the agency distinguishes between assessment-based measures calculated with OASIS and claims-based utilization measures drawn directly from Medicare claims (CMS home health quality measures). For hospice, a similar logic applies.

For claims-based measures, CMS defines a measurement window, identifies the relevant hospice episodes and beneficiaries, and then extracts data from the claims that fall within that window. The data collected includes patient-level information, administrative data, service dates, levels of care, revenue codes, visit counts, discharge status codes, and other required fields. Accurate and timely data collection is essential to comply with CMS regulations and to ensure proper reimbursement and quality measurement. Those data points are then run through published measure algorithms.

CMS periodically refreshes publicly reported hospice quality data on Care Compare. In the November 2025 quarterly refresh, for example, CMS reported that claims-based measures were based on claims data from the first quarter of 2023 through the fourth quarter of 2024. By contrast, assessment-based measures and CAHPS scores relied on slightly different date ranges that align with their own collection and submission timelines (CMS hospice public reporting background and announcements).

Providers receive their claims-based quality scores ahead of public posting in the Hospice Provider Preview Reports. These are delivered through the CASPER reporting system, and hospices have a 30-day preview period to review the scores and, if necessary, request that CMS review the measure calculations. CMS is explicit that submission errors that a hospice did not correct before the data correction or claim processing deadlines will not be treated as inaccuracies for preview review purposes (CMS public reporting key dates for providers).

In practice, that means the real work of accuracy happens long before the preview report arrives. By the time you see a measure score, the underlying claims may be several quarters old and largely locked in place. Data from claims-based measures is also used to evaluate the adequacy of current payment rates and to inform future updates of the hospice benefit.

The Transition From HIS to HOPE and What It Means for Claims

While this article focuses on claims-based measures, it is important to place them in the broader context of the significant transition now underway in HQRP. CMS has finalized the introduction of the Hospice Outcomes and Patient Evaluation (HOPE) tool as the new assessment mechanism for hospices, replacing the retrospective, chart-abstracted Hospice Item Set.

HOPE was finalized in the FY 2025 Hospice Wage Index Final Rule as the standardized, real-time assessment tool that will collect quality data and feed new HQRP measures. CMS has scheduled HOPE data collection to begin on October 1, 2025, which is the first day of fiscal year 2026 (CMS HOPE page, HOPE technical information).

Unlike HIS, which focuses on whether process steps occurred at admission and discharge based on chart review, HOPE is designed as a patient-level assessment that captures clinical status, symptom burden, functional abilities, and care needs at multiple points. CMS has also defined HOPE Update Visits that occur during the first 30 days after election, with hospices required to submit up to two update assessments depending on length of stay (CMS HOPE page).

For claims-based reporting, this transition does not eliminate existing claims-based measures. Instead, it adds richer clinical and process context around the same episodes already visible in claims. Your claims will continue to drive the HVLDL and HCI scores. HOPE-based measures will sit alongside them, providing an additional window into how well your team is addressing pain, dyspnea, medications, and other core domains.

For leadership teams, the implication is straightforward. You will have more quality data streams to manage, not fewer. That reality makes it wise to tighten claims-related processes now instead of waiting for HOPE implementation to add another layer of complexity.

Building Strong Internal Processes for Claims-Based Quality

Claims-based measures reward hospices that treat billing data as a clinical data asset, not just as a payment requirement. That requires a level of integration among clinical, billing, and quality teams that may not exist today, especially in organizations that grew quickly or rely heavily on manual processes.

The starting point is clear definitions and consistent use of revenue codes, modifiers, and levels of care on claims. For example, the pattern of routine home care, continuous home care, inpatient respite, and general inpatient care across a stay can affect how your claims map to quality measures. Inaccurate coding can distort those patterns.

Billing teams should be equipped with clear guidance, built into policies and system logic, that ties each service type and setting to the correct revenue codes and visit counts. Reference to the CMS guidance manual is essential to ensure compliance with data collection and submission requirements for hospice claims-based reporting. Where your software allows, automated edits and validation rules can prevent the submission of claims that are missing required elements or that contain obvious inconsistencies.

On the clinical side, visit documentation must support what is ultimately billed. If a nurse or social worker completes an urgent end-of-life visit but the record is not documented and transmitted in time for the billing cycle, the claim may never reflect that contact. Over time, those missing visits can reduce your Hospice Visits in the Last Days of Life scores, even though the care actually occurred.

Hospices are required to complete and submit a standardized set of items for each patient to capture patient-level data, regardless of payer or patient age. We have seen similar themes in our work with home health agencies and other providers. The organizations that manage cost reports and regulatory filings most effectively tend to be the same ones that maintain disciplined, year-round processes for collecting and validating operational data. Last-minute reconstruction of entire fiscal years is rarely as accurate as building a reliable infrastructure from the start. Claims-based HQRP reporting benefits from that same mindset.

Managing Timeframes, Refresh Cycles, and Preview Periods

HQRP operates on defined reporting and refresh schedules that are easy to overlook when teams are focused on daily operations. Data must be submitted within a particular reporting period to ensure compliance with HQRP requirements. Claims-based measures typically aggregate data over rolling multi-quarter periods, and the public refresh schedule lags behind the close of the measurement period.

For example, in the August 2025 public reporting refresh, HIS-based quality scores reflected admission and discharge data from the fourth quarter of 2023 through the third quarter of 2024. By contrast, the claims-based measures in that refresh relied on claims from the first quarter of 2022 through the fourth quarter of 2023. In November 2025, CMS updated claims-based measures to use claims data from the first quarter of 2023 through the fourth quarter of 2024 (CMS hospice public reporting background and announcements).

Hospices should pair that public refresh schedule with the internal reality that claims corrections and adjustments are subject to their own filing timetables. Delayed or incomplete claims corrections may fall outside the data capture window CMS uses for a given preview report.

During the preview period, providers can review their HIS and claims-based measure scores and, if they suspect a calculation error, follow CMS procedures to request review. However, CMS emphasizes that it will treat the underlying HIS and claims data on file at the time of measure calculation as the definitive record. Failure to correct submission errors before data submission or claim extraction deadlines is not considered grounds for revising the scores during preview (CMS public reporting key dates for providers).

Taken together, these timelines argue for regular internal monitoring of claims patterns throughout the year rather than waiting for quarterly or annual reviews. Hospices must submit HIS-Admission and HIS-Discharge records within 30 calendar days of the patient’s admission and discharge dates. If your internal reports show a sustained decline in visits late in the hospice stay or a rising rate of live discharges, it is better to understand and address the underlying issues early than to discover the trend for the first time in a preview report.

Integrating Claims-Based Measures Into Quality Governance

Claims-based measures sit at the intersection of clinical practice, operations, and finance. Boards and executive teams increasingly expect to see them integrated into routine quality dashboards and strategic planning, not presented as stand-alone statistics. Organizations use these dashboards to measure performance, evaluate, and compare hospice quality measures, ensuring compliance thresholds are met and data accuracy is maintained.

A practical approach is to frame claims-based metrics in terms that clinicians recognize. The Hospice Visits in the Last Days of Life measure can be paired with internal tracking of after-hours call volume, crisis visits, and family satisfaction with end-of-life support. The Hospice Care Index can be broken down into its component indicators for internal analysis, even if only the composite is publicly reported. Management uses the HCI to identify gaps in care and adjust staffing or policies to improve patient outcomes.

In many organizations, quality and compliance committees already review CAHPS results, grievance trends, and chart-based quality audits. Claims-based patterns deserve a permanent seat at that table. When a hospice is also analyzing Medicare hospice caps or state-level requirements, as we have discussed in other contexts, the same data discipline supports both financial and quality oversight.

External education resources from CMS, including web-based training modules on HQRP and HOPE, can help cross-functional teams develop a shared understanding of how quality measures are defined and calculated. CMS has published training specifically oriented toward getting started with HQRP and understanding public reporting, as well as detailed didactic courses on HOPE implementation (HQRP training and education library, HHS HQRP training guidance). Building those materials into staff education plans can help demystify the relationship between day-to-day documentation and downstream quality scores.

Preparing for a More Data-Intensive Future

If there is a single theme that unites the current direction of hospice regulation, it is the steady shift toward more granular, patient-level data and more public transparency. HOPE is a clear example of this trend, replacing retrospective abstraction with real-time assessment at multiple timepoints. CMS has also expanded its use of composite measures and star ratings in other programs, and hospice is following that pattern.

For claims-based reporting, this trajectory likely means that the interplay between assessment data, survey responses, and claims patterns will only become more complex. The technical specifications change from year to year, and CMS periodically adjusts the look-back periods, risk adjustment methods, and measure definitions.

Hospices that treat HQRP as an annual compliance exercise will find it difficult to keep up with that pace of change. Those that build stable, cross-functional processes around documentation, billing, and quality monitoring are better positioned to adapt as new measures and tools are introduced.

In prior work, we have seen how outsourced accounting and specialized regulatory support can help smaller organizations maintain that level of discipline without building large in-house back offices. The same holds in hospice, where the demands of claims-based quality measurement can strain already lean administrative teams.

Bringing It All Together

Claims-based reporting within the Hospice Quality Reporting Program is not a separate project or one more portal to manage. It is the natural extension of your existing claims operations, repurposed to define how your hospice appears on public quality dashboards and in CMS reports.

Every visit logged, every level of care coded, and every discharge disposition recorded on a claim contributes to a larger narrative about how your organization cares for patients and families. As CMS launches HOPE and refines HQRP, that narrative will only gain detail.

By treating claims data as a shared clinical and financial resource, aligning documentation with billing, and monitoring trends regularly rather than sporadically, hospices can use claims-based measures not only to stay compliant but to inform genuine quality improvement.

If you would like to explore how claims-based HQRP measures interact with your broader Medicare compliance and financial reporting, including hospice caps and cost reporting, we are ready to help you map out a practical plan. Click the button below to schedule a time to chat.