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ESRD Quality Incentive Program - Public Reporting & Certificates

Guidance for explaining the procedures pertaining to Public Reporting and Certificates as they relate to the ESRD Quality Incentive Program. The webpage includes performance score quality reports, public use data files and performance score certificates.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 04, 2020

The Medicare Improvements for Patients and Providers Act (MIPPA) requires that CMS and facilities inform beneficiaries about facility performance under the ESRD QIP. CMS does this in two primary ways:

Posting information to Care Compare on the Medicare.gov website and elsewhere
Requiring dialysis facilities to post a Performance Score Certificate (PSC) that outlines how well it performed under the ESRD QIP

Care Compare

CMS posts each facility’s Total Performance Score (TPS) and scores on each individual measure on the Care Compare website.

Performance Score Summary Reports

CMS also posts a Performance Score Summary Report (PSSR) data file, a sizeable spreadsheet containing the performance values of each facility for the given Payment Year (PY).

Public Use Data Files

Part of the ESRD QIP rulemaking process includes proposing and finalizing performance values, CMS calculates values for each clinical measure, along with the minimum TPS, for the applicable PY. In order for the stakeholder community to repeat and verify the accuracy of CMS’s calculations, CMS releases to the public a sizeable spreadsheet containing the facility-level data used to calculate those percentiles. CMS removes the facility identifiers in these reference files.

Performance Score Certificates

MIPPA also requires that CMS furnishes each dialysis facility with a PSC that documents the facility’s TPS. The law requires that facilities display their PSC in a prominent location within fifteen business days of the PSC’s release. CMS provides new PSCs annually in both English and in Spanish. Sample PSCs can be found below.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.