1. The ABC’s of Hospice, COP’s, ADR’s and RAC’s Kim Kranz, RN, MS Kathy Baker, RN, MSN

2. 35 diverse, non-profit programs providing home and community based services CHAP accredited, Medicare certified Home Health CHAP accredited, Medicare certified Hospice Named to the Best Place to Work in Pennsylvania since 2004 Earned the distinction of “Best Practices in Homecare and Hospice” by Pennsylvania Homecare Association Recognized from Modern Healthcare as one of the Top 100 Best Places to Work in Healthcare in the nation Recognized for implementing Best Practices in Operations Management Serving Central Pennsylvania for 41 years 1,000 employees in thirteen counties Hospice Average Daily Census of 475

3. Overview Why are they looking at us Who is looking at us What are they looking at What can we do to protect ourselves and patient access

4. Why are They Looking at Us Rapid growth of hospice Diagnosis mix, more non cancer diagnosis than ever before Health care reform and rise in health care costs Revised COP’s

5. NHPCO Facts & Figures 2012

7. Primary Diagnosis20102009 Cancer35.6%40.1% Non-Cancer Diagnoses64.4%59.9% Heart Disease14.3%11.5% Debility Unspecified13.0%13.1% Dementia13.0%11.2% Lung Disease8.3%8.2% Other5.4%4.5% Stroke or Coma4.2%4.0% Kidney Disease (ESRD)2.4%3.8% Non-ALS Motor Neuron1.2%1.9% Liver Disease1.9%1.8% HIV / AIDS0.3%0.4% Amyotrophic Lateral Sclerosis (ALS)0.4% NHPCO Facts & Figures 2012

8. COP’s Patient Rights 418.52 Comprehensive assessment 418.54 Plan of Care 418.56 –Individualized –Patient and family focused –Problem identification with appropriate interventions and services needed for palliation of symptoms and management of the terminal illness –Review at least every 15 days

9. COP’s Quality assessment and performance improvement 418.58 Hospice care in the skilled nursing facility 418.112

10. Who is Looking at Us MAC/ADR’s MA/BPI RAC ZPIC

11. Who is Looking at Us Medicare Administrative Contractor (MAC) Effective June 13, 2011 CGS assumed home health and hospice for Jurisdiction 15 which includes Pennsylvania www.cgsmedicare.com –Ensure services are paid correctly –Medical review –Customer service –Provider education

12. Who is Looking at Us Additional Development Request (ADR) Notified of ADR via FISS Prepayment Documentation is requested from the provider to assist CGS in making coverage determination Providers submits the medical documentation for review Nurse reviewer reviews the documentation and makes payment determination

13. Widespread Edits – greatest risk of inappropriate payment Current Widespread edits include:  Length of stay of 999 days  Routine level of care and a length of stay greater than 730 days  General Inpatient Services with at least 7 or more days  Hospice care provided in a long term care facility with a diagnosis of Debility (799.3) and a length of stay greater than 180 days  Previous denials

14. ADR’s Top denial reason: Documentation does not support terminal diagnosis

15. Who is Looking at Us Medicaid The Department of Public Welfare, Bureau of Program Integrity (BPI) Retrospective monitoring –Medically unnecessary –Inappropriate level of care –Inappropriate billing –Incomplete CTI –Hospice related services billing

16. Who is Looking at Us Recovery Audit Contractor Program (RAC) Created by the Medicare Modernization Act of 2003 Paid on a contingency fee basis 9%- 12.5% of identified overpayment and underpayment –Dependent on the region –For Pennsylvania it is Diversified Collection Services (DCS) Post-payment

17. RAC’s Purpose of RAC’s Detect and correct past improper payments Prevent future improper payments Types of RAC Audits Automated review –No medical record needed Complex review –Medical record review required

18. RAC’s RAC Audit Timeframes Will not be able to review claims paid prior to October 2007 Can look back 3 years RAC Issues Must be approved by CMS Issue review board members mostly clinicians List of issues is on the RAC websites

19. Who is Looking at Us Zone Program Integrity Contractor (ZPIC) There are 7 ZPIC regions Non-contingency fee payment Oversight by CMS Medicare Integrity Group Can be both prepayment and post-payment

20. ZPIC’s Purpose of ZPIC’s To investigate and identify potential cases of Medicare fraud and abuse Will look at areas not targeted by RAC audits Criteria for hospice Length of stay Nursing home patient Documentation to support the terminal illness

21. ZPIC’s ZPIC Audit Timeframes No limit Must comply with regulations –Within one year of payment for any reason –One to four years for good cause –After four years for suspicion of fraud

22. ZPIC’s ZPIC Audit Process Data mining to audit claims –Unusual trends –Potential errors –high volume, high cost –Fraud May send out request for information Could conduct site visits and medical reviews

23. What We Can Do Review all policies/procedures and processes in relation to the COP’s Develop an ADR process –Who will watch for notification of ADR’s –Who will review –Who will prepare them and send them –Record all ADR’s and the disposition of each –Appeal when appropriate

24. What We Can Do Develop a process to look at each new referral for eligibility Consultation for use of debility diagnosis Conduct record reviews of all debility and long length of stay diagnosis Educate staff at all levels on good documentation –Use actual examples of documentation Take a picture

25. What We Can Do Review the EMR and revise as needed –Require timely documentation –Encourage use of narrative and free text to avoid boilerplate information –Discourage use of cut and paste Utilize tools and resources that are available –Documentation tools from CGS –Local Coverage Determinations (LCD’s) Utilize standard assessment tools for the right diagnosis –ESAS, FAST, PPS, NYHA

27. References NHPCO Facts and Figures: Hospice Care in America National Hospice and Palliative Care Organization www.cms.gov www.cms.hhs.gov/RAC