Hospice Quality Reporting: HOPE, HCI, and What Payment Penalties Do Not Measure

The hospice quality reporting payment penalty reduces a hospice’s annual Medicare payment update when it fails to meet required data submission standards. It measures compliance with reporting requirements. A nurse’s account of the care, a family’s experience and the visits recorded on Medicare claims answer different questions. If you work in quality, clinical operations or billing, you may see the distance between what the hospice submits and what happened to the patient. That is where the reporting story can connect to hospice fraud.

The Hospice Quality Reporting Payment Penalty Cuts the Annual Update

The reduction was two percentage points for fiscal years 2014 through 2023 and became four percentage points from fiscal year 2024 onward. Under Medicare’s hospice payment rules, the reduction comes off the annual update used to set payment rates.

The submission threshold is at least 90% of required assessment records submitted and accepted by the Centers for Medicare & Medicaid Services within 30 days of the relevant event. For the Hospice Item Set, that event was admission or discharge. For HOPE, it also includes completion of an update visit.

The calendar year of the data and the fiscal year of the payment consequence are different. The fiscal year 2027 final rule ties calendar year 2025 submissions to fiscal year 2027 payment updates, and calendar year 2026 submissions to fiscal year 2028 updates.

The program also requires caregiver survey participation through an approved vendor, subject to exemptions. Claims-based measures use administrative data Medicare already receives, so they require no additional quality-data submission. A hospice can satisfy that part of reporting through its claims while those same claims show a concerning pattern of visits or discharges.

From HIS to HOPE

The hospice HOPE quality reporting payment reduction carries the submission requirement into a new patient assessment system. The Hospice Item Set collected data through September 30, 2025. Hospice Outcomes and Patient Evaluation began on October 1, 2025.

Medicare describes HOPE as a way to collect standardized information about patient needs and changes during care. It retains key admission items from HIS and adds assessments during the stay. Depending on the length of the stay, the hospice must submit up to two HOPE Update Visits during the first 30 days after election. That gives the reporting program information about the patient beyond the admission and discharge records.

For a clinical team, those additional assessments connect the patient’s baseline condition with changes that can inform the plan of care. For someone reviewing the hospice’s reporting, the relevant records now include the update visits as well as the beginning and end of the stay.

The system changed too. The fiscal year 2026 final rule moved HOPE submissions to iQIES and set February 15, 2026 as the last day the older QIES system would accept HIS records.

The transition also came with a material exception. Under the transition waiver, all HOPE records with target dates from October 1 through December 31, 2025 count as timely because of the new tool and platform migration.

What the Hospice Quality Measures Tell Us

The Hospice Quality Reporting Program draws on patient assessments, caregiver experience and Medicare claims. Each reaches a different part of care, and each leaves a different question for the people who were there.

The CAHPS Hospice Survey Captures the Caregiver’s Experience

The Consumer Assessment of Healthcare Providers and Systems Hospice Survey, known as CAHPS, asks family members or friends about the care of a patient who died while receiving hospice services. It covers such matters as communication, timely help, respect, symptom support and training the family to care for the patient. Those are questions an accepted assessment file cannot answer on the family’s behalf.

Hospices use CMS-approved vendors to administer the survey. An organization that owns, operates or staffs a hospice cannot administer its own survey or act as the survey vendor for another hospice. That separation matters when the subject is what families experienced.

The Hospice Care Index Combines Patterns Across the Stay

The Hospice Care Index, or HCI, combines ten claims-based indicators into a score ranging from zero to ten. Higher scores mean the hospice met more of the indicator thresholds. The Medicare technical report includes gaps in skilled nursing visits, weekend nursing minutes, live discharges, transitions through hospitals, spending and provision of higher levels of care.

The index deliberately combines several dimensions. The report explains that claims may leave out circumstances affecting a single measure, while repeated problems across different parts of care deserve closer attention. A billing specialist may recognize the discharge pattern. A nurse may know why visits became scarce. The index brings those patterns into view together.

Hospice Visits in the Last Days of Life

Hospice Visits in the Last Days of Life measures the proportion of patients receiving in-person visits from a registered nurse or medical social worker on at least two of the final three days of life. Its focus is narrower than the HCI: professional contact near death.

That makes it useful for a specific question about when staff reached the patient. The clinical notes and the caregiver’s account carry the next questions about what the visit addressed and whether the family received the help it needed. Hospice billing evidence connects the services represented on a claim to the care described in the patient record.

Hospice Quality Reporting Submitted Versus Quality Performance

Submitting the data is not the same as delivering the care. Medicare calls the program pay for reporting. A compliant submission answers the reporting question. The quality measures and the underlying care records answer the clinical questions.

Medicare’s own figures show the size of the missing-data problem. In its fiscal year 2027 assessment of reporting compliance, the agency reported HIS noncompliance of 20.07% in fiscal year 2023 and 20.37% in fiscal year 2026. The agency said it had observed no significant improvement in reporting compliance after the penalty increased. Approximately a fifth of hospices still left the agency with insufficient data for measuring quality and helping consumers compare providers.

Medicare increased the penalty. Families still had to make a health care decision with information missing. For an insider examining a provider, a clean submission history still leaves the substance of the care to examine.

The economics help explain why visit patterns matter. Medicare generally pays hospice by the day, while making visits costs the provider money. A 2026 Kansas State University working paper on hospice quality and reimbursement used visits per patient day as a measure of effort and quality in its California analysis. In its small, noisy sample comparing visits with caregiver ratings for 2018, the relationship was limited:

Its finding supports reading the measures together: the resources devoted to visits and the family’s experience capture different aspects of care.

HOPE, HCI, and SSVI Answer Different Questions

HOPE supplies patient assessment data. HCI summarizes claims-based care indicators. The Service and Spending Variation Index identifies unusual patterns across utilization and spending for closer oversight. The fiscal year 2027 final rule describes SSVI as a way to identify hospices with several areas of concern that may warrant medical review or other investigation.

The direction of the scores also differs. A higher HCI score reflects more indicator thresholds met. A higher SSVI score signals greater potential concern.

Medicare finalized a Care Compare icon for HOPE reporting failures, using calendar year 2026 submission data, no earlier than October 1, 2027. Public release of HOPE quality results was separately anticipated for November 2027, subject to analysis of the data.

What an Insider Adds to the Quality Data

An insider can connect submission records, claims and clinical notes to the decisions behind them. That connection gives a pattern meaning. We examine the reporting history alongside the patient record and the instructions staff received.

We connect submission and acceptance records showing what reached Medicare with the claims and clinical notes for the same patient and period. Provider preview reports address what the public measures were going to show. Claims describe the visits and services billed. The people providing care can explain the patient’s condition, the work performed and pressure to change the chart.

The distinction reaches back beyond HOPE. In its 2015 study of hospice in assisted living facilities, the HHS Office of Inspector General found that hospices typically provided fewer than five hours of visits and received about $1,100 per week for each beneficiary receiving routine home care there. Questions about admission and recertification reach the clinical support for keeping a patient on hospice.

The whistleblowers’ complaint against Agape Senior Community illustrates why the instructions behind a chart matter. A nurse alleged that she recorded a patient driving and going to a store, then received instructions to suppress good days:

The government’s complaint against Evercare Hospice supplies a parallel about discharge decisions. It alleged that management blocked a patient’s requested departure from hospice because the census was too low. Enrollment pressure supplied the alleged reason for keeping the patient.

These accounts show what firsthand knowledge can add when a file presents a tidy account of a patient’s condition or stay. The business decision behind the entry can be the fact an outside reader would never see.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work with insiders to connect what they know about the care and the decisions to the Medicare claims.

When You Know What Happened Behind the Submission

If your work in hospice quality, clinical care or healthcare billing shows a gap between the submitted account and the care patients received, speak to one of our whistleblower experts about that gap. We build the case with you around the patient evidence, the payment and who directed the reporting, bringing in hospice fraud whistleblower lawyers who understand clinical documentation and Medicare billing. We stay beside you through the work of building your strongest hospice whistleblower case.