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Regulations: A Year in Review and A Look to the Future.

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Presentation on theme: "Regulations: A Year in Review and A Look to the Future."— Presentation transcript:

1 Regulations: A Year in Review and A Look to the Future

2 Outline Nebraska Hospice Landscape State Licensure and Regulations Survey Deficiencies Hospice Wage Index Quality Reporting Proposed Rulemaking Change Requests Provider Bulletins Hospice Scrutiny –OIG –MEDPAC –RAC –PEPPER Fiscal Intermediary Information Resources


4 NebraskaNational Population1,855,525313,878,238 Total Deaths15,0222,512,991 Medicare Beneficiaries Deaths12,7212,022,574 Medicare Hospice Beneficiary Admissions 7,847 62% of Medicare deaths 1,257,735 62% of Medicare deaths Medicare Hospice Beneficiary Deaths 5,953 46.8% of Medicare deaths 897,379 44.4% of Medicare deaths Medicare Hospice Total Days of Care468,804 days89,817,308 days Medicare Hospice Mean Days/Beneficiary Medicare Hospice Median Days/Beneficiary 60 days 21 days 71 days 25 days Medicare Hospice Discharged Alive12%18% Medicare Hospice Total Payments Medicare Hospice Mean Payment/Beneficiary $71,282,532 $9,084 $14,882,743,292 $11,842 2012 Demographics & Hospice Utilization



7 2012 Medicare Hospice Beneficiaries Location of Care (days)

8 2012 Medicare Hospice Beneficiaries Levels of Care (days)

9 2012 Length of Stay

10 State of Nebraska

11 Nebraska Department of Health and Human Services Medicaid Physical Health Managed Care RFP to be released this summer and will be effective July 1, 2015 – will add hospice and certain other services Medicaid hospice services for persons in nursing facilities or receiving Aged and Disabled Waiver assisted living services will continue to be excluded

12 Nebraska Department of Health and Human Services Managed Long Term Services and Support (MLTSS) Medicaid MLTSS RFP will not be released prior to September 1, 2015 and will not go live prior to January 1, 2017

13 Nebraska Department of Health and Human Services Pamela Kerns, RN, Administrator 402-471-3651 Hospice-specific Web page cddlabs_hospice_hospice.aspx

14 Nebraska Hospice Licensure Title 175, Chapter 16 Effective May 1, 2010 regs/regsearch/Rules/Health_and_Human_S ervices_System/Title-175/Chapter-16.pdf

15 State Operational Manual (SOM) Updated – March 7, 2014 All Chapters: Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs-Items/CMS1201984.html Appendix M – Hospice Guidance/Guidance/Manuals/downloads/som107a p_m_hospice.pdf

16 CMS CY2013 Survey Deficiency Data 3,970 Active hospice providers 1,301 recertification surveys 33% of active providers surveyed

17 CMS CY2013 Survey Deficiency Data L0543 – Plan of Care –POC not individualized; missing or incomplete documentation; lack of IDT collaboration; lack of evidence of patient/family collaboration of POC goals L0545 – Content of Plan of Care –Missing or inaccurate documentation; physician orders missing

18 CMS CY2013 Survey Deficiency Data L0530 – Content of Comprehensive Assessment –Incomplete medication profiles; lack of updated medication profiles in patient’s home L0555 – Coordination of Services –Services provided by IDT that were not on POC and interventions on POC that were not provided

19 CMS CY2013 Survey Deficiency Data L0547 Content of Plan of Care –POC contained services missing frequency of care to be provided L0591 – Nursing Services –Hospice aides performing tasks outside of scope of practice; RN on-call issues; delays in RN visits; RN unable to visit frequency for pt needs

20 CMS CY2013 Survey Deficiency Data L0629 – Supervision of Hospice Aides –Supervision of hospice aides varied from 16 days to more than 30 days L0557 – Coordination of Services –RN documented at assessment patient declined chaplain as involved with community church – chaplain documented repeated messages to schedule a visit; Patient had private duty aide services – no documentation to show coordination of care with private agency

21 CMS CY2013 Survey Deficiency Data L0533 – Update of Comprehensive Assessment –RN performed dyspnea assessment but did not communicate change in status to IDT – other members of IDT did not take into consideration when updating the POC L0671 – Clinical Records –Lacked patient signature forms, IDT notes including aide, volunteer, and chaplain

22 Patient Protection and Affordable Care Act (PPACA)

23 Hospice Payment Reform Will occur no earlier than Oct. 1, 2013, or FY2014 Revise methodology for RHC Not required to change payment for other levels of care

24 Hospice Payment Reform Medicare Hospice Payment Reform: Hospice Study Technical Report, April 24, 2013 Payment/Hospice/Downloads/Hospice-Study-Technical- Report-4-29-13.pdf Medicare Hospice Payment Reform: Analyses to Support Payment Reform, Abt Associates, May 1, 2014 Payment/Hospice/Downloads/May-2014- AnalysesToSupportPaymentReform.pdf

25 Medicare Care Choices Model Initiative to test new payment and service delivery model Beneficiary to receive palliative care services from certain hospices while concurrently receiving curative services Choices/ Choices/faq.html

26 Hospice Wage Index

27 FY2014 Medicare Wage Index CBSA Code State County Code County NameFY2014 Wage Index FY2014 Routine Home Care FY2014 Continuous Home Care FY2014 Inpt Respite FY2014 General Inpt NE28200084 Other Counties 0.8894 0.8937 144.20 147.55 841.57 861.15 151.76 155.18 645.04 659.89 NE3070028540Lancaster and Seward 0.9906 0.9553 155.05 154.29 904.90 900.47 160.60 160.67 690.01 687.81 NE3654028270Cass, Douglas, Sarpy, Saunders, and Washington 1.0222 0.9847 158.44 157.51 924.67 919.23 163.36 163.29 704.05 701.14 NE4358028210Dakota and Dixon 0.9176 0.9248 147.22 150.96 859.21 881.00 154.22 157.95 657.58 673.99 *Red amount indicates proposed FY2015 rates as published in Proposed Rule May 2, 2014

28 Budget Control Act of 2011 “Sequestration” Sequestration Order issued March 1, 2013 Medicare Fee-for-Service claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. s/2013/0313/1005.html

29 CMS FY2015 Hospice Wage Index Proposed Rule May 2, 2014 Payment/Hospice/Hospice-Regulations-and-Notices- Items/CMS-1609-P.html

30 Key Elements in FY2015 Proposed Rule Data analysis for consideration in hospice payment reform No hospice payment reform proposed for FY2015 Changes Proposed –Time frames for Notice of Election (NOE) and new Notice of Termination/Revocation –Attending physician is patient decision –Cap self report and overpayment expected 5 months after close of cap year –Hospice quality reporting updates –ICD-9 to ICD-10 Update Payment Update –2% payment update (net 1.3%) for FY2015 –Sequestration means NO payment update for FY2015 Comments Requested –Definitions of “terminal illness” and “related conditions” –Part D and hospice communication

31 Analyses for Payment Reform 1.No skilled visits in last 48 hours of life 2.Analysis of GIP, Continuous Home Care and Inpatient Respite 3.Live discharges a.Frequency of live discharges b.Live discharges and readmissions after hospital stay 4.Medicare expenditures in Part A and B outside the MHB 5.Medicare expenditures in Part D when patient has elected hospice

32 % of Patients with No Skilled Visits Days before Death % of Patients Last day of life28.9% of patients Last 2 days of life 14.4% of patients Last 3 days of life 9.1% of patients Last 4 days of life 6.2% of patients Skilled visits include nurse, social worker, therapies

33 Lowest % of Patients with No Visits in Last 2 Days of Life State% with No Visits WI5.7% ND7.3% VT7.5% TN7.5% KS8.5%

34 Highest % of Patients with No Visits in Last 2 Days of Life State% with No Visits NJ23% MA22.9% OR21.2% WA21% MN19.4%

35 Percentage of days by level of care Level of Care Percentage of Total Days Routine Home Care97.4% Continuous Home Care0.4% Inpatient Respite Care0.3% General Inpatient Care1.9%

36 GIP Utilization Patient utilization: 77.3% of patients electing hospice did not have a GIP stay during their hospice election Hospices providing GIP 21.1% of hospices did not bill for a single day of GIP in CY2012

37 GIP Utilization National average = 1.9% of days are GIP Provide GIP –5-10% = 195 hospices –10% or more = 46 hospices Any GIP Provided? Number of Hospices No969 Yes2,758

38 Location of GIP

39 Length of GIP Stay by Location

40 Continuous Home Care Data Hospice CharacteristicBilling Continuous Home Care Hospices that billed Continuous Home Care 42% of hospices billed at least one day of CHC 4 hospicesbilled more than 10% of their days as CHC 40 hospicesaccounted for 46% of all CHC days 1 hospice> 25% of all CHC days 9.4% of hospices> 50% provided to patients in nursing homes

41 Inpatient Respite Utilization Patient Utilization 3.4% in CY2012 used at least 1 day Hospices providing Inpatient Respite 26% of hospices did not bill for a single day of IRC during CY2012

42 Ongoing Monitoring and Review CMS states ongoing monitoring of GIP, CHC, and IRC utilization Review will include: –Identify hospices with aberrant utilization patterns –Identify hospices that may be in violation of the CoPs or payment regulations Hospices identified will be referred to Survey and Certification Office of Financial Management Center for Program Integrity for further investigation

43 Live Discharges Year% of Live Discharges 200013.2% 201218.1% July 1 2012Revocations separated from hospice-initiated live discharges 2013 data Revocations39% No longer terminally ill58%

44 Rates of Live Discharges 2010 Live Discharge rates by state CT12.8% MS40.5% % of Patients Discharged Alive Number of Hospices 0 – 9.9%1,601 10% - 19.9%1,315 20% - 29.9%371 30% - 39.9%133 40% +282 Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012

45 100% Live Discharge Rate 71 hospices in CY2012 –Average length of stay: 193 days –National average lifetime LOS: 95.4 days CMS states: We have shared this information with the Office of Financial Management and with the Center for Program Integrity for their review and follow-up.

46 Live Discharge and Readmissions Hospice Discharge Hospital Admission Expensive test/procedure $126 M Hospital Discharge Hospice Readmission 2010 Data 13,770 patients of 182,172 live discharges – 7.5%

47 Live Discharge and Readmission by State MSVA OKTX ALNJ SCGA MDLA

48 Medicare A and B Outside Hospice Benefit Part A or B ServicePercentage of $$ Spent DME7.1% Inpatient care28.6% Outpatient Part B services16.9% Other Part B services (physician, practitioner, labs and diagnostic tests, ambulance transports, and physician office visits) 37.4% Skilled Nursing Facility Care5.7% Home Health Care4.5%

49 States where Medicare A and B Outside the Hospice Benefit is Highest WV FL TX MS SC

50 Part D Expenditures During a Hospice Stay CY2012 –Total Part D spending: $417.9 million – Paid by Medicare: $334.9 million All drug types Paid by: –Medicare –States –Beneficiaries –Other payers

51 Highest Part D Expenditures by State ID WV AL OK

52 CY2012 Total Non-Hospice Medicare Spending For beneficiaries after hospice election Parts A & B: $710.1 million Part D: $334.9 TOTAL: $1.3 Billion dollars Note: 51.6 % of $1.3 billion -- 373 hospices Average total per beneficiary: $1,289 in non- hospice costs


54 Notice of Election File the Notice of Election with MAC within 3 calendar days after effective date of election Failure to submit: Medicare will not cover and pay for days of hospice care from the effective date of election to the date of filing of the NOE. Provider may not bill beneficiary.

55 NOE Filing File Notice of Election (NOE) as soon as possible after the election occurs If filed ASAP: –Limits ability of other Part A, B and D providers to bill in error –Provides up to date information on face-to-face encounter –Identify current benefit period –Provide smooth transitions for sequential billing

56 Attending Physician The attending physician has been identified by the patient and was his or her choice NEW: File a change of attending physician form with the hospice that states that the patient is changing his or her attending physician

57 Notice of Termination Filing a Notice of Termination of Election –When hospice election is ended due to discharge, the hospice must file a notice of termination/revocation of election within 3 calendar days after the effective date of the discharge, unless it has already filed a final claim for that beneficiary.

58 Notice of Revocation Filing a Notice of Revocation of Election. –When the hospice election is ended due to revocation, the hospice must file a notice of termination/revocation of election with its Medicare within 3 calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary

59 Payment Penalty for No Quality Reporting For FY 2014 and subsequent fiscal years –if the hospice does not submit hospice quality data, payment rates are equal to the rates for the previous fiscal year increased by the applicable market basket percentage increase, minus 2 percentage points. –Applies only to the fiscal year involved –Will not be taken into account in computing the payment amounts for a subsequent fiscal year.

60 New Cap Reporting File its cap determination notice with its Medicare contractor No later than 5 months after the end of the cap year (that is, by March 31st) Remit any overpayment due at that time. If a provider fails to file, payments to the hospice would be suspended in whole or in part, until a self-determined cap determination is filed

61 Data Submission for Quality Reporting Data Submission Requirements under the Hospice Quality Reporting Program. –Hospices must submit to CMS data on measures selected in a form and manner, and at a time, specified by the Secretary.

62 Submission of HIS data Submission of Hospice Quality Reporting Program data. –Complete and submit an admission Hospice Item Set (HIS) and a discharge HIS for each patient admission to hospice, regardless of payer or patient age. –HIS is a standardized set of items intended to capture patient-level data.

63 Contract with CAHPS® Vendor Medicare-certified hospices must contract with CMS-approved vendors to collect the CAHPS® Hospice Survey data on their behalf and submit the data to the Hospice CAHPS® Data Center.

64 CAHPS Survey Data Collection Deaths in Prior Calendar Year Survey and Reporting < 50 deaths Exempt from CAHPS data collection and reporting 50 to 699 deaths n = 2,326 hospices Survey and report all cases >= 700 deaths n = 274 hospices Sample of 700 will be drawn under equal probability design

65 Quality Reporting Appeals Reconsiderations and appeals of Hospice Quality Reporting Program decisions. –May request reconsideration of a CMS decision about Hospice Quality Reporting Program for a particular reporting period. –Reconsideration requests to CMS no later than 30 days from the date identified on the annual payment update notification provided to the hospice.

66 Quality Reporting Appeals Reconsiderations and appeals of Hospice Quality Reporting Program decisions. –Submission requirements available on the CMS Hospice Quality Reporting Web site on –A hospice dissatisfied with CMS decision may file an appeal with the Provider Reimbursement Review Board


68 Eligibility Reminder that the hospice medical director must consider at least the following information per our regulations at §418.25 (b): –Diagnosis of the terminal condition of the patient –Other health conditions, whether related or unrelated to the terminal condition. –Current clinically relevant information supporting all diagnoses.

69 Resources for Eligibility Multiple public sources available to assist in determining whether a patient meets Medicare hospice eligibility criteria: –industry specific clinical and functional assessment tools –information on MAC websites We expect hospice providers to use the full range of tools available to make responsible and thoughtful determinations regarding terminally ill eligibility


71 Feedback on Hospice EHR Have hospices have adopted an EHR? What functional aspects of the EHR do hospices find most important? –ability to send or receive transfer of care Information –ability to support medication orders/medication reconciliation Can hospice EHR communicate with other healthcare providers? –acute care hospitals –physician practices –skilled nursing facilities? Ins decision Should CMS develop electronic clinical quality measures for hospice providers? Benefits and limitations?


73 ICD-9 ICD-9-CM diagnosis codes will continue to be used for hospice claims reporting until October 1, 2015 Diagnosis reporting on hospice claims must adhere to ICD-9-CM coding conventions and guidelines Applies to both the principal diagnosis and the reporting of additional diagnoses

74 Medicare Code Editor Edits Will implement certain edits from Medicare Code Editor (MCE) Report errors in the coding of claims data ALL hospice claims effective October 1, 2014 or later Inappropriate principal or secondary diagnosis codes, per ICD-9-CM coding conventions and guidelines? Returned to Provider (RTP) for correction and resubmission prior to payment

75 Multiple Diagnoses on Claim Year % of claims submitted with one diagnosis FY201077.2% First quarter (10/1/2012 through 12/31/2012) 72% FY201367%



78 Definition of Terminally Ill CMS states: “Because hospice care is unique in its comprehensive, holistic, and palliative philosophy and practice, we want to ensure that the hospice services under the Medicare hospice benefit are preserved and not diluted, or unbundled in any way.”

79 Possible Definition of Terminal Illness “Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of six months or less”.

80 Possible Definition of Related Conditions “Those conditions that result directly from terminal illness; and/or –result from the treatment or medication management of terminal illness; and/or –which interact or potentially interact with terminal illness; and/or –which are contributory to the symptom burden of the terminally ill individual; and/or –are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less”.


82 Comments Requested on Possible Changes to Part D Regulations Would require that a Part D sponsor communicate and coordinate with Medicare hospices in determining coverage for drugs whenever –a coverage determination process is initiated or –a hospice furnishes information regarding a beneficiary’s hospice election and/or drug profile

83 Comment on Hospice Initiated Communication Report a beneficiary’s hospice status Includes –notice of election (NOE) –Notice of termination/revocation (NOTR) May also provide –drug profile information –identification of drugs unrelated to the terminal illness or related conditions –explanation of why the drug is unrelated

84 Comment on Hospice Initiated Communication Permits hospices to initiate communication with the beneficiary’s Part D sponsor Considering requiring Part D sponsors to accept NOE and NOTR information as use for coverage until official CMS notification is received Expect sponsors to have processes in place to confirm CMS-reported data and communicate with hospice

85 Comment on Part D Sponsors using Proposed Definitions Propose that Part D sponsor be required to use the criteria described in the definitions of “terminal illness” and “related conditions” Determine whether drug is unrelated to the terminal illness and related conditions Satisfies the beneficiary-level hospice PA

86 Comment on Independent Review Process CMS considering Separate and distinct from the enrollee appeals process Independent Review Entity (IRE) decision would be binding on both the Part D sponsor and the hospice


88 Reports from Beneficiaries Anecdotal reports from Medicare hospice beneficiaries They are not receiving medications related to their terminal illness and related conditions from their hospice One reason stated – “those medications are not on the hospice’s formulary”

89 Hospice Formulary CMS states: If the drugs on the hospice formulary are not providing the relief needed, then the hospice must provide alternatives in order to relieve pain and symptoms EVEN if it means providing drugs that are not on the hospice formulary

90 CoP for Drug Coverage 418.202(f), –Hospices are to cover all drugs which are reasonable and necessary to meet the needs of the patient in order to provide palliation and symptom management of the individual's terminal illness and related conditions. Treatment decisions should be driven by clinical appropriateness, rather than costs

91 CMS Comment on Medication Management CMS states: –Hospices should use thoughtful clinical judgment, with a patient-centered focus, when developing the hospice plan of care, including the recommendations for medication management


93 What we know Ongoing meetings on Part D and hospice with no easy resolution Part D plans instructed to continue current practices through 2015 Some hospices continue to request Part D payment for vitamins, calcium, nasal spray and throat lozenges Some Part D plans refuse to pay for any drugs for hospice patients

94 Relatedness No clear line between related and unrelated to terminal illness and related conditions Could be contributing to prognosis… Determination needs: –Expertise of hospice physician –Documentation in medical record of “why” the drug is unrelated


96 Standardized Form Developed by the National Council of Prescription Drug Programs (NCPDP) CMS has stated that they have reviewed the form and “tweaked” it in a couple of places Will begin sending it through the Paperwork Reduction Act (PRA) process for approval May take years…

97 Quality Reporting

98 ACA (H EALTH R EFORM L EGISLATION ) Requires hospices to submit data on selected quality measures to receive annual payment update for fiscal year 2014 and subsequent fiscal years. Beginning in FY 2014, hospices that do not submit required quality measure data will have their market basket rate reduced by 2% for that FY.

99 ACA (H EALTH R EFORM L EGISLATION ) CMS must take steps to make hospice quality measure data available to the public (no timeline given). The published quality measures must receive endorsement from a consensus body (e.g. NQF), with exceptions.

100 F IRST T WO Y EARS Measures 1.NQF #0209: Comfortable Dying = Percentage of patients who were uncomfortable because of pain on the initial assessment (after admission to hospice) whose pain was brought to a comfortable level within 48hours

101 F IRST T WO Y EARS 2.Structural Measure: Participation in a QAPI program that includes at least 3 quality indicators related to patient care

102 2014 F INAL R ULE Data collection and submission for QAPI Structural measure and NQF 0209 are discontinued CY 2013 was the last data collection; CY 2014 was the last data submission for these measures FY 2015 is the last payment determination year for these measures

103 2014 Q UALITY R EPORTING NQF #0209 and QAPI Structural Measures – No longer required for quality reporting *Comfortable Dying measure still supported by NHPCO

104 Q UALITY R EPORTING - HIS Hospice Item Set (HIS) Patient level data collection tool Data used to calculate 7 new measures

105 Q UALITY R EPORTING - HIS Six NQF Endorsed Measures: NQF 1634Hospice and Palliative Care -- Pain Screening NQF 1637 Hospice and Palliative Care –Pain Assessment NQF 1638 Hospice and Palliative Care -- Dyspnea Treatment NQF 1639 Hospice and Palliative Care -- Dyspnea Screening

106 Q UALITY R EPORTING - HIS Six NQF Endorsed Measures: NQF 1617 Patients Treated with an Opioid who are Given a Bowel Regimen NQF 1641 Treatment Preferences One Modified NQF Measure: NQF 1647Beliefs/Values Addressed

107 Q UALITY R EPORTING - HIS For specifications of proposed measures -- National Quality Forum (NQF) Final Report on Palliative and End of Life Measures of-Life_Care.aspx#t=1&s=&p of-Life_Care.aspx#t=1&s=&p= (or Google search: NQF Palliative end of life measures endorsement summary)

108 Q UALITY R EPORTING - HIS Implementation starts July 1, 2014 Hospices who fail to report quality data via the HIS system in 2014 will have a 2% market basket reduction for FY2016 Reconsideration request process

109 Q UALITY R EPORTING - HIS All Medicare-certified hospices must submit. New but on track for initial survey – need to prepare Newly certified hospices that receive notice of their CMS certification number on or after November 1, 2014 excluded (proposed)

110 Q UALITY R EPORTING - HIS Must collect and submit data on admission and discharge of every patient All payers All ages

111 Q UALITY R EPORTING - HIS Quality measure scores not calculated for all patients -  18 years and older  LOS of > 7 days for some But still need to collect/submit for all admissions starting 7/1/2014

112 Q UALITY R EPORTING - HIS Two Forms ADMISSION Sections A, F, I, J, N, Z Contains administrative items and care process items. DISCHARGE Sections A, Z Contains a limited set of administrative items and 2 discharge items.

113 Q UALITY R EPORTING - HIS The HIS is not – a patient assessment instrument and will not be administered to the patient and/or family or caregivers The HIS is - a standardized mechanism for abstracting data from the medical record

114 Q UALITY R EPORTING - HIS Record Completion and Data Submission Electronically online Ongoing basis 14 days from admission to complete HIS-Admission record 7 days from discharge to complete HIS-Discharge record 30 days from a patient admission or discharge to submit

115 Q UALITY R EPORTING - HIS Have policy/procedure in place related to:  Creation of HIS  Retention of HIS submission

116 Q UALITY R EPORTING - HIS CMS Resources – Data Collection CMS HQRP Web site – Hospice Item Set page –HIS Manual and Change Table –HIS Training slides –Fact Sheet –Q & A Assessment-Instruments/Hospice-Quality- Reporting/Hospice-Item-Set-HIS.html Quality Help Desk:

117 Q UALITY R EPORTING - HIS CMS Resources – Data Submission CMS HQRP Web site - HIS Technical Information page QTSO Website –Technical Training modules (Webex) –HART Training modules –Registration for IDs Technical Support QTSO Help Desk:

118 H OSPICE CAHPS (E XPERIENCE OF C ARE S URVEY ) Post-death caregiver survey Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys Borrows heavily from NHPCO FEHC Requires contract with a vendor for survey administration

119 H OSPICE CAHPS Implementation Mandatory “dry run” for at least 1 month in first quarter of CY 2015 Continuous participation starts April 1, 2015 Participation will affect the FY 2017 payment determination year Dedicated survey website (TBA) Reconsideration request process Will be included in public reporting eventually

120 H OSPICE CAHPS Eligibility: Patients over age of 18 LOS of at least 48 hours No non-familial legal guardians No non-USA home addresses No known caregiver or contact information Request not to be contacted

121 H OSPICE CAHPS Must use a vendor approved by CMS List of approved vendors provided close to the launch of national implementation. Summer 2014 interested vendors may apply to become an approved vendor

122 H OSPICE CAHPS Measures derived from survey questions: 1.Hospice Team Communication (5) 2.Getting Timely Care (2) 3.Treating Family Member with Respect (2) 4.Providing Emotional Support (2) Source = proposed rule

123 H OSPICE CAHPS 5.Getting Help for Symptoms (4) 6.Information Continuity (1) 7.Understanding the Side Effects of Pain Medication (1) 8.Getting Hospice Care Training (Home Setting of Care Only) (4) Source = proposed rule

124 H OSPICE CAHPS Sampling: Hospices send caregiver information to vendors each month Hospices with fewer than 50 decedents during the prior calendar year are data collection and reporting requirements for payment determination. Hospices with 50 to 699 decedents in the prior year (n = 2,326 in 2012) will be required to survey all cases. For large hospices with 700 or more decedents in the prior year (n =274 in 2012), a sample of 700 will be drawn under an equal- probability design.

125 Change Requests (CRs) July 2013 through June 2014

126 Medicare Benefit Policy Manual Chapter 9 - Coverage of Hospice Services Under Hospital Insurance (Rev. 156, 06-01-12) Guidance/Guidance/Manuals/Downloads/bp 102c09.pdf

127 CR 8727 Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual Released May 1, 2014 Effective Date: August 4, 2014 Updates the hospice policy chapter to incorporate policy language from existing regulations, prior rules, an OIG report and two CR, and to clarify existing policy. No changes were made to existing policy. Guidance/Guidance/Transmittals/2014-Transmittals- Items/R188BP.html

128 CR 8620 CWF Editing for Vaccines Furnished at Hospice - Correction Released February 6, 2014 Was rescinded and replaced by Transmittal 1737, dated April 28, 2014 Guidance/Guidance/Transmittals/Downloads/ R1339OTN.pdf

129 CR 8569 Enforcement of the 5 day Payment Limit for Respite Care Under the Hospice Medicare Benefit Released February 5, 2014 Was rescinded and replaced by Transmittal 2928 to restore information from CR8358 that was erroneously omitted. Guidance/Guidance/Transmittals/Downloads/ R2867CP.pdf

130 CR 8358 Additional Data Reporting Requirements for Hospice Claims Released January 31, 2014 To provide clarifying information and examples; technical corrections of Transmittal 2747, dated July 26, 2013 Guidance/Guidance/Transmittals/Downloads/ R2864CP.pdf

131 CR 8358 Additional Data Reporting Requirements for Hospice Claims Released July 26, 2013 Effective Date: April 1, 2014 Implementation Date: January 6, 2014 Additional date for: visit reporting for GIP, reporting facility NPI; reporting of infusion pumps and prescription drugs Service-Payment/Hospice/Downloads/R2747CP.pdf

132 Provider Bulletins (PBs) July 2013 through June 2014

133 Provider Bulletin 13-65 FFY 2014 Medicaid Hospice Rates Issued: September 9, 2013 Effective Date: October 1, 2013 65.pdf

134 Provider Bulletin 13-79 January 1 through December 31, 2014 Base Rates for Levels 101 through 105 Issued: December 11, 2013 Effective Date: January1, 2014 79.pdf

135 Provider Bulletin 14-21 Provider Enrollment Process Changes Issued: April 2, 2014 Effective Date: May 1, 2014 2014-21.pdf

136 Provider Bulletin 14-22 Nebraska Medicaid Recovery Audit Contract (RAC) Program Issued: April 29, 2014 22.pdf

137 Revalidation of Provider Enrollment All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from their MAC.

138 Revalidation of Provider Enrollment Letters to be sent between now and 6/23/2015 Will be mailed (USPS) to address on file CMS website Enroll/

139 Hospice Scrutiny

140 Office of Inspector General (OIG) Fiscal year 2014 work plan related to hospice: Hospice in assisted living facilities –ALF residents have the longest lengths of stay in hospice care Hospice General Inpatient Care –Review the appropriate use of hospice general inpatient care publications/archives/workplan/2014/Work-Plan-2014.pdf

141 MedPac March 2014 Report Recommendation to “carve-in” the Medicare Hospice Benefit for Medicare Advantage participants

142 HealthDataInsights, Inc. RAC for Region D Listed audit issue for hospice –Face-to-Face Evaluation for Re-certification of Hospice Care Medical documentation will be reviewed to determine timeliness of the face-to-face re- certification NewIssues.aspx

143 PEPPER Program for Evaluating Payment Patterns Electronic Report Hospice Target Areas Live Discharges Long Length of Stay

144 PEPPER A report summarizing a hospice’s Medicare claims data in areas of risk. Compares a hospice’s claims data with aggregate statistics for other hospices in the state, MAC/FI jurisdiction and the nation Data obtained from the UB-04

145 PEPPER PEPPER does not identify the presence of improper payments, but can be used as a guide for auditing and monitoring efforts Training and Resources: Hospice.aspx

146 Fiscal Intermediary Information

147 CGS 1-877-299-4500 Option 1: Hospice Customer Service Rep Option 2: EDI Customer Service Rep Option 3: Provider Enrollment department Option 4: Overpayment Recovery department Interactive Voice Response (IVR) number 1-877-220-6289 for beneficiary eligibility, claim status, check and general information

148 myCGS Web Portal New enhancements If your organization/office is not already signed up for the myCGS web portal, go to html html

149 CGS Claims Denied February 2014 – May 2014 277,779 hospice claims submitted 43,488 claim submission errors 3,406 hospice claims reviewed 2,164 denied

150 CGS Hospice Medical Review Top Denials for February – May 2014 5PTER: Six-month prognosis not supported 5PPOC: Plan of care not updated timely 5PCER: Certification requirements not met 56900: ADR information not received 5PNOE: Election Statement incomplete, missing, untimely

151 Medical Review Hierarchy Level of care Physician visits Terminal status Plan of Care (POC) including review of the POC every 15 days Certifications including face-to-face (FTF) Election Statement

152 CGS Current Widespread Edits Length of stay > 730 days Seven or greater GIP days on claim Code Q5003 and Q5004 with primary diagnosis of Debility, unspecified (799.3) and length of stay > 180 days Length of stay between 150-365 days and non- oncologic diagnosis code Previous denials for selected beneficiary eview_edits.html

153 Additional Document Request (ADRs) Check for ADRs at least once per week ADR Quick Reference Tool materials/pdf/ADR_QRT.pdf Chapter 3: Inquiry Menu materials/pdf/Chapter3_Inquiry_Menu.pdf materials/pdf/Chapter3_Inquiry_Menu.pdf

154 Resources CGS ml –Frequently asked questions –Education materials (Quick Reference Tools) –Claim information –E-mail list serve

155 Resources CMS Hospice Center Type/Hospice-Center.html –CMS Q&A –Change Requests and Transmittals –CMS manuals –MLN Matters Articles –Open Door Forum

156 Resources Nebraska Hospice and Palliative Care Association Membership Only Section Unless you have changed: User name: FirstnameLastname Password: nhpca2013

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