8/27/2018. Stay Cool in the Heat! Tips & Tools to Manage Current Hot Topics.

Transcription

1 Stay Cool in the Heat! Tips & Tools to Manage Current Hot Topics Alicia Sterritt, MSW Director of Quality & Compliance The Carolinas Center Annette Kiser, MSN, RN, NE-BC Chief Compliance Officer Teleios Collaborative Network Who are they? Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. The OIG has been at the forefront of the Nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 100 other HHS programs. Examples of other programs they protect CDC, National Institute of Health, Food and Drug Administration and more 09/12/ /12/18 3 1

2 OIG Work Plan and Portfolio Reports The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections. OIG Portfolio Reports summarize OIG's body of work in a program area and identifies trends in payment, compliance, oversight, or fraud vulnerabilities requiring priority attention and action. 09/12/18 4 OIG Work Plan In evaluating potential work plan projects to undertake, the OIG considers a number of factors, including: mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directives; requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget; top management and performance challenges facing HHS; work performed by other oversight organizations management's actions to implement OIG recommendations from previous reviews; and potential for positive impact. 09/12/18 5 OIG WORK PLAN and Hospice Hospice Care. Hospice care provides comfort for terminally ill beneficiaries and supports family and other caregivers. Problems include inadequate oversight of certification surveys and staff licensure requirements, care planning failures, inadequate medical and nursing care, fraudulent enrollments undertaken without beneficiary consent, and enrollment of beneficiaries who are not terminally ill. 09/12/18 6 2

3 Active Hospice Work Plan Items June 2018 Medicare Payments Made Outside of the Hospice Benefit Prior OIG reviews have identified separate payments that should have been covered under the per diem payments made to hospice organizations. We will produce summary data on all Medicare payments made outside the hospice benefit, without determining the appropriateness of such payments In addition, we will conduct separate reviews of selected individual categories of services (e.g., durable medical equipment, prosthetics, orthotics and supplies, physician services, outpatient) to determine whether payments made outside of the hospice benefit complied with Federal requirements. 09/12/18 7 Active Hospice Work Plan Items August 2017 Duplicate Drug Claims for Hospice Beneficiaries Previous OIG work found that Medicare may have paid twice for prescription drugs for hospice beneficiaries, once under the Part A per diem rate and again under Part D. We will follow up on this work and review the appropriateness of Part D drug claims for individuals who are receiving hospice benefits... We will also determine whether Part D continues to pay for prescription drugs that should have been covered under the per diem payments made to hospice organizations. 09/12/18 8 Active Hospice Work Plan Items June 2017 Trends in Hospice Deficiencies and Complaints Previous OIG reports identified numerous vulnerabilities and raised concerns about the limited enforcement actions against poorly performing hospices. As part of OIG s ongoing commitment to address quality of care, we will determine the extent and nature of hospice deficiencies and complaints and identify trends. 09/12/18 9 3

4 Active Hospice Work Plan Items November 2016 Hospice Home Care Frequency of Nurse On-Site Visits to Assess Quality of Care and Services Medicare requires that a registered nurse make an on-site visit to the patient's home at least once every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient s needs (42 CFR (h)(1)(i)). We will determine whether registered nurses made required on-site visits to the homes of Medicare beneficiaries who were in hospice care 09/12/18 10 Active Hospice Work Plan Items November 2016 Review of Hospices Compliance with Medicare Requirements When a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary s terminal illness and related conditions. We will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements. 09/12/18 11 Trends in OIG Hospice Work Plan Items Compliance with Medicare Regulations and Oversight Quality of Care Per Diem Payment and Separately billed to Medicare Part D and/or Medicare Part B 09/12/

5 Tips and Tools How can your Hospice ensure you are operating toward: 1. Compliance with Medicare Regulations and Oversight Discussion 2. Quality of Care Discussion 3. Per Diem Payment and Separately billed to Medicare Part D and/or Medicare Part B Discussion 09/12/18 13 OIG Portfolios Remember: OIG Portfolio Reports summarize OIG's body of work in a program area and identify trends in payment, compliance, oversight, or fraud vulnerabilities requiring priority attention and action. 09/12/18 14 OIG Portfolios & Reports Current and Recent Hospice Work 09/12/

6 OIG Recommendations to Improve the Medicare Hospice Program 1. Strengthen the survey process to better ensure that hospices provide beneficiaries with needed services and quality care. 2. Seek statutory authority to establish additional remedies for hospices with poor performance. 3. Develop and disseminate additional information on hospices to help beneficiaries and their families and caregivers make informed choices about their care. 4. Educate beneficiaries and their families and caregivers about the hospice benefit. 09/12/18 16 OIG Recommendations (Cont.) 5. Promote physician involvement and accountability to ensure that beneficiaries get appropriate care 6. Strengthen oversight of hospices to reduce inappropriate billing 7. Take steps to tie payment to beneficiary care needs and quality of care to ensure that services rendered adequately serve beneficiaries needs, seeking statutory authority if necessary 09/12/18 17 Prior OIG Reports Two key requirements of the Medicare hospice benefit are for the beneficiary to sign an election statement and for a physician to certify the beneficiary as terminally ill. Together, these provide critical safeguards to ensure that the beneficiary understands the hospice benefit and that the physician is involved in determining whether the beneficiary is appropriate for hospice care. We found that: hospice election statements lacked required information or had other vulnerabilities the physician did not meet requirementssuch as composing a narrative-when certifying, and appeared to have limited involvement in determining that the beneficiary was appropriate for hospice care. 09/12/

7 Prior OIG Reports We found that hospices billed one-third of GIP stays inappropriately, costing Medicare $268 million in Hospices commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms. 09/12/18 19 Prior OIG Reports Medicare payments for hospice care in ALFs more than doubled in 5 years. Hospices provided care much longer for beneficiaries in ALFs than for beneficiaries in other settings. This report raises concerns about the financial incentives created by the current payment system and the potential for hospices to target beneficiaries in ALFs because they may offer the hospices the greatest financial gain. 09/12/18 20 Work Plan for Physician Services These items can pertain to palliative care: Physician Home Visits Reasonableness of Services Will determine if Medicare payments for Evaluation & Management home visits were reasonable and necessary MD must document the medical necessity of a home visit Prolonged Services Reasonableness of Services Will determine if Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements Necessity is considered to be rare and unusual Medicare Claims Processing Manual outlines requirements that must be met in order to bill for a prolonged E/M service code 09/12/

8 DRUG DISPOSAL 09/12/18 22 Drug Disposal Federal The Hospice does not have authority to dispose of medications at death or discharge in the home COP (e)2 The hospice must have written policies and procedures for the management and disposal of controlled drugs in the patient s home Disposal of controlled drugs in hospices that provide inpatient care directly must dispose of controlled drugs in compliance with the hospice policy and in accordance with State and Federal requirements. The hospice must maintain current and accurate records of the receipt and disposition of all controlled drugs 09/12/18 23 Drug Disposal Federal Legislation in process: H.R Safe Disposal of Unused Medication Act would allow a hospice employee to handle lawfully dispensed controlled substances of a deceased hospice patient to assist with disposal of the controlled substances, so long as such disposal occurs onsite in accordance with applicable law 09/12/

9 Drug Disposal SC Non-Controlled Substances Upon discharge or death of a patient, a Hospice shall release the unused medications to the patient, family member, or responsible party, as appropriate. 09/12/18 25 Drug Disposal SC Controlled Substances / Hospice Home Care Upon the death of a patient receiving outpatient services from a hospice, ownership of unused medications related to the care of the patient shall transfer to the hospice for immediate disposal. SECTION Disposal of deceased patient's unused controlled substances. This Photo by Unknown Author is licensed under CC BY-SA 09/12/18 26 S.C. Code Section You must: 1. Establish a written procedure 2. The hospice nurse shall record the name and quantity of each unused controlled substance in the presence of a witness. Then Conduct immediate disposal at the site of care The nurse should perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing of the disposal OR Immediate mail-back to a collector registered pursuant to 21 C.F.R Section If participating in immediate mail-back to a registered collector, the hospice nurse shall deposit the unused medications into the mailback envelope and seal the envelope at the site of outpatient services. 09/12/

10 Drug Disposal SC Controlled Substances/Hospice Facility For the purpose of disposing unused controlled substances, a hospice facility is a long-term care facility The hospice facility shall dispose of unused Schedule II, III, IV, and V controlled substances in accordance with 21 C.F.R. Sections and /12/18 28 Drug Disposal NC NC STOP Act Strengthen Opioid Misuse Prevention Act of 2017 Hospice and Palliative Care providers prescribing targeted controlled substances: Targeted controlled substances = Schedule II and III opioids and narcotics Shall provide oral and written information upon commencement of treatment to the patient and his or her family regarding the proper disposal of such targeted controlled substances. This information shall include availability of permanent drop boxes or periodic drug takeback events that allow for the safe disposal of controlled substances. 09/12/18 29 Drug Disposal Tool Box DEA website for Drug Disposal Excellent Resources Search for an Authorized Collector where you can search for collectors in your area. Make sure to extend the search to 50 miles. Contains great information for disposing of medication...use as a resource for providing caregivers. In addition, look for specific information in your community. Visit the website of your local county sheriff s office, or call them to find out more information on take-back events. You can then be assured that you are in compliance as you provide oral and written information on proper disposal. 09/12/

11 CERTIFICATION OF TERMINAL ILLNESS 09/12/18 31 Scrutiny of Eligibility There is more scrutiny of the patient s eligibility for the hospice benefit and the higher levels of care CMS has concern that hospices are turning the Medicare benefit into a chronic care benefit Are patients being admitted too soon and receiving hospice services for too long? CMS, its contractors, the OIG, MACs, and States are conducting audits 09/12/18 32 Certification Based on the attending physician s and medical director s clinical judgment Two physician signatures are needed at the initial certification Only one signature is needed at subsequent recertifications Be sure that the clinical information to support the prognosis is filed in the medical record 09/12/

12 Certification Form Must contain the following depending on the benefit period Statement: Six months or less prognosis if the terminal illness runs its normal course Benefit period dates to which the certification or recertification applies Physician narrative Physician narrative attestation Face-to-face encounter date (3 rd or later benefit period) Face-to-face encounter attestation (3 rd or later period) Signature and date by the physician(s) No stamps 09/12/18 34 Timing of Certification (a) Timing of certification Obtain written certification of terminal illness for each period Obtain the written certification before submitting a claim Exception. If you cannot obtain the written certification within 2 calendar days after a period begins, you must obtain an oral certification within 2 calendar days and the written certification before claim submission 09/12/18 35 Verbal Certification Must include the same components as the written 6 month prognosis statement Name of certifying MD Date of verbal certification Staff member s signature and date Since it is not an order any staff member can obtain and document Need from both the hospice medical director and the attending physician 09/12/

13 Physician Narrative Must support the prognosis Can be written by either the attending physician or hospice Medical Director Cannot be composed by staff Cannot contain check boxes or standard language MD must attest that they composed the narrative based on a review of the patient s medical record or, if applicable, an examination of the patient 09/12/18 37 Physician Narrative Write a brief summary of the information considered or used to establish eligibility Weight loss Specify lbs. in months Hospitalizations Note # hospitalizations in past 6 months (or other timeframe) Functional status Note comparative changes over time Comorbidities, secondary diagnoses Summarize status of diseases Other Note any recent infections or wounds, oxygen use, problematic symptoms 09/12/18 38 Timing of Recertification 15 days prior to the beginning of a benefit period The recertification form may be signed no earlier than 15 calendar days prior to the start of the next benefit period For 3rd or later benefit periods, the face-to-face encounter must be completed before the narrative and certification are completed F2F findings must be used in making the recertification decision 09/12/

14 Face-to-Face Encounter Required for 3rd & subsequent benefit periods A 2-day delay is allowed for exceptional circumstances such as a patient in a pain crisis Applies only at admission, not recerts Can be completed by a hospice physician or hospice nurse practitioner Requires an attestation that the visit was completed NPs must provide findings for review by the certifying MD when completing the certification 09/12/18 40 Timing of F2F Encounter Within 30 days prior to the beginning of the 3rd or later benefit period Document the Face-to-Face (F2F) encounter The date of the Face-to-Face encounter and the date of the attestation do not have to be the same date BUT both dates must be listed on the attestation form Can be done the same day of the new benefit period 09/12/18 41 Late Face-to-Face Late F2F = Patient is not eligible for the hospice benefit Must discharge the patient from the Medicare Hospice Benefit not from hospice services Can readmit the patient to the benefit after completion of the face-to-face encounter Need new election statement, certification from hospice medical director, updated comprehensive assessment, updated plan of care 09/12/

15 USING DATA TO MONITOR RISKS 09/12/18 43 Comparative Billing Reports (CBRs) Educational tool from Palmetto GBA Not intended to be punitive or an indication of fraud Gives insight into your billing patterns and utilization of services in comparison to your peers Action: Develop a self-audit tool to assist in determining what may be missing from the medical record Will help avoid the following: Claims submission errors Denials for insufficient documentation Potential overpayments Medical review activity 09/12/18 44 Long LOS CBR Letter is to inform you that Palmetto GBA concluded a Comparative Billing Report (CBR) of Jurisdiction M for Hospice Aggregate Length of Stay (ALOS). To receive this CBR, you must meet one of the following criteria: Average length of service per beneficiary greater than the 80th percentile for your state % Beneficiaries with aggregate stay greater than one year greater than the 80th percentile for your state % Beneficiaries with aggregate stay greater than two years greater than the 80th percentile for your state 09/12/

16 NCLOS ecbr 09/12/18 46 PEPPER Program for Evaluating Payment Patterns Electronic Report Utilizes Medicare claims information to compare your data to other hospices in the state, the Palmetto GBA JM Region and the Nation. Shows your data for the past 3 years so you can identify patterns in the data. Does not signify that you are doing anything wrong, but it is imperative that you know what your data shows CMS considers outliers to be at risk of receiving improper Medicare payments. 09/12/18 47 PEPPER Target Areas Live Discharges No Longer Terminally Ill Live Discharges Revocations Live Discharges with LOS Days Long Length of Stay (greater than 180 days) Continuous Home Care in Assisted Living Facility Routine Home Care in Assisted Living Facility Routine Home Care in Nursing Facility Routine Home Care in Skilled Nursing Facility Claims with Single Diagnosis Code No General Inpatient Care or Continuous Home Care Long General Inpatient Care Stays Greater than 5 Days 09/12/

17 PEPPER Data NC Sample Using PEPPER Data Use as a guide for auditing and monitoring efforts Look at outlier scores in red and bold Consider if variations are due to billing errors such as improper use of Q codes Changes over time can signify changes in billing practices which warrants further review Don t wait for PEPPER to know your data! Review internal reports ongoing to identify concerns in advance 09/12/18 50 Palliative Care ecbrs Palmetto GBA is producing electronic Comparative Billing Reports (ecbrs) applicable to palliative care Focus is on Evaluation & Management (E/M) services and compliance with coverage and documentation requirements Past ecbrs: New Patient Office Visit CPT Codes Established Patient Office Visit Subsequent Hospital Visit CPT Codes /12/

18 FEDERAL AUDITORS 09/12/18 52 Audits Who s Watching Now? Medicare Administrative Contractor (MAC) Palmetto GBA Office of Inspector General (OIG) State Medicaid Integrity Contractors Supplemental Medical Review Contractor (SMRC) Recovery Audit Contractor (RAC) Unified Program Integrity Contractor (UPIC) All of these can audit Hospice or Palliative Care 09/12/18 53 New Recovery Auditor Single auditor for hospice, home health & DME Performant Recovery Inc. Covers all states Higher likelihood of hospices being audited Working with CMS for approval of issues Outliers will be the first audited 09/12/

19 New Entity UPIC Combines the work of the following: ZPIC (Medicare) MIC (Medicaid) Program Safeguard Contractors (PSCs) Medicare-Medicaid Data Match (Medi-Medi) Focus: Fraud, waste and abuse SafeGuard Services (SGS) won the contract Will cover South East Region NC, SC, GA, AL, FL, TN, VA, WV, Puerto Rico, Virgin Islands 09/12/18 55 Clinical Denial Reasons Eligibility Documentation doesn t support six months or less prognosis Higher Level of Care Documentation doesn t support use of GIP or CHC Physician Narrative Statement Inadequate Plan of Care Review not documented for all dates IDG Involvement Lack of evidence to show core disciplines participated in POC review 09/12/18 56 Technical Denial Reasons #1 Automatic Denial Failure to submit records Physician Certification Invalid or missing Election Statement Untimely or missing required elements Face to Face Encounter Missing or untimely 09/12/

20 Targeted Probe & Educate (TPE) New Medicare audit process to target non-compliant providers based on claims data MACs will select the area of review based on data analysis Billing aberrations Utilization of services Ranking among peers Can be post-pay or prepay reviews Will request claims for each round of review Education is provided after round if indicated Provider may have up to 3 rounds of audits 09/12/18 58 Initial Probe for TPE Provider receives a notice of review letter for TPE Reason for review Letter will specify how many claims will be requested Wait for ADRs before sending documentation Palmetto GBA has 30 days to review documentation Failure to respond could lead to a referral to the RAC or UPIC 09/12/18 59 Additional TPE Rounds If there is a high error rate, the provider may have up to 3 rounds Each MAC sets its own error rate Provider will receive a detailed letter of the results The MAC provides education to discuss the reasons for denials Once the error rate is below the MAC threshold, provider will be released from TPE and not reviewed again on the same topic for at least 1 year 09/12/

21 Further Action After TPE If denial rates continue to be high after the 3 rd round, the provider may be subject to additional action Extrapolation Referral to UPIC or RAC 100% prepay review 09/12/18 61 FY 2019 HOSPICE FINAL RULE 09/12/18 62 Physician Assistants Effective January 1, 2019: Will be recognized as having a role in Hospice Will be allowed to serve as the Hospice patient s attending physician Will not be allowed to complete the certification of terminal illness Will not be allowed to do the face to face encounter for certification purposes. Will not be allowed to replace physician for IDT 09/12/

22 North Carolina and PAs North Carolina Hospice Licensing definition: "Attending Physician" means the physician licensed to practice medicine in North Carolina who is identified by the patient at the time of hospice admission as having the most significant role in the determination and delivery of medical care for the patient. 09/12/18 64 South Carolina and PAs SC DHEC Licensing Section 100-Definitions E. Attending Physician. The physician who is identified by the patient as having the most significant role in the determination and delivery of medical care to the patient. F. Authorized Healthcare Provider. An individual authorized by law and currently licensed in South Carolina to provide specific care, treatment, or services to patients such as, advanced practice registered nurse, physician assistant. NN. Physician Assistant. An individual currently licensed as such by the South Carolina Board of Medical Examiners 09/12/18 65 Trends in Utilization Usage Year 2017 Compared to Year 2014 Number of Patients Increasing Yearly Medicare Spending Increasing Yearly Medicare Spending While on Hospice Continues to be High Average LOS Decreasing from 88.2 days to 79.7 Days 09/12/

23 Non-Hospice Spending Medicare Part A and B spending on patients that also have Hospice has decreased, but still $566 million in 2017 Medicare Part D spending on patients while in Hospice has risen every year since spending was close to $381 million CMS will consider ways to address the issue through future regulatory reform and/or program integrity efforts 09/12/18 67 Drug Reporting Effective October 1, 2018 A hospice can submit total, aggregate DME and drug charges on the claim OR continue submitting individual drug charges CMS encourages providers to select one consistent mechanism for reporting this data, either aggregate or individual 09/12/18 68 Quality Reporting Highlights The Hospice and Palliative Care Composite Process Measure will be added to Hospice Compare in Fall When the Composite Measure is reported on Hospice Compare, CMS will no longer display the 7 individual measures. The public will have the ability to view the individual measures by expanding the screen on the webpage. 09/12/

24 Quality Reporting Highlights CMS will announce any future public reporting efforts through sub-regulatory means. PUF data will be added to Hospice Compare as a separate information section of website PUF contains information on: Utilization, payment, submitted charges, primary diagnoses, sites of service, and hospice beneficiary demographics organized by CMS Certification Number and state. 09/12/18 70 RESOURCES 09/12/18 71 OIG Resources OIG About Us Webpage OIG Work Plan OIG Reports - Search box top corner Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio 09/12/

25 Drug Disposal Resources Drug Disposal Federal Drug Disposal SC and Drug Disposal NC 09/12/18 73 Medicare Resources Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance Guidance/Guidance/Manuals/Downloads/bp102c0 9.pdf FY 2019 Hospice Final Rule 06/pdf/ pdf 09/12/18 74 Audit Contractors Review Contractor Directory Interactive Map and-systems/monitoring-programs/medicare-ffs- Compliance-Programs/Review-Contractor- Directory-Interactive-Map/ Performant Recovery RAC for Hospice Cotiviti RAC for Palliative Care 09/12/

26 Data Resources Palmetto GBA ecbr Information for Hospice cat/providers~jm%20home%20health%20and%20hosp ice~eservices%20portal~ecbr PEPPER Information Palmetto GBA ecbr Information for Part B /docscat/providers~jm%20part%20b~eservices%20port al~ecbr Comparative Billing Reports & Resources for Part B 09/12/18 76 Audit Preparation Resources Hospice Law Library Articles Checklist for Hospice Audit Interviews and Conferences content/uploads/2016/08/checklist-audit- Interviews.pdf 09/12/18 77 QUESTIONS? Alicia Sterritt asterritt@cchospice.org Annette Kiser akiser@teleioscn.org 78 26

27 Federal Audit Areas of Focus The information listed below was gleaned from a Medicaid Integrity Contractor questionnaire used for hospice audits. Similar information may be requested by the Unified Program Integrity Contractor (UPIC). Medicaid Compliance Experience 1. Do you have a compliance department that routinely reviews Medicaid claims for compliance with applicable laws, regulations and policies? ( ) Yes ( ) No 2. Do you, or designated staff, access the State Medicaid rules and regulations on a regular basis? 3. If so, by what means do you access the information? 4. Within the dates of service outlined in HI s Engagement Letter, has your facility been audited by the State or Federal government? 5. If yes to previous question, when, and by whom? 6. Has your facility had to pay back an overpayment as a result of those Federal or State audits? 7. If so, when and how much were the recoupments? ( ) Yes ( ) No ( ) Yes ( ) No *If yes, please provide a copy of the audit. ( ) Yes ( ) No The Carolinas Center Page 1 of 2

28 Internal Control Policies and Procedures To assist us in understanding your organization structure and learn more about your organization, please provide the following: 1. Organizational Chart/Medical Directors these charts depict the organizational structure, key personnel, and past Medical Directors of your organization. 2. Operating Procedures/Agreements These may include some/all of the following: Hospice Care Services Agreement Nursing facility agreement for inpatient, respite, room and board and purchased services from provider. Medicaid Billing Instructions for Hospice Services Medicaid Hospice Benefits Provider Standards for Hospice Client Medicaid Eligibility Criteria Process for Election of Hospice Services Prior Authorization Guidelines Guidelines for Decline in Clinical Status Discharge Guidelines Billing Hospice Services 3. Policies, such as: Policies for Hospice Care Definition for Terminal Illness Certification Requirements Discontinuation of Services Policy Recertification of Terminal Illness Revocation Policy 4. Audited financial statements for the last two years. In addition, please be prepared to discuss: The manner in which documents for Medicaid services are created, i.e., who creates the documents; who verifies their accuracy; how are the documents stored, etc. Explain how information recorded in a medical chart flows to the billing process. Who prepares and reviews the bills to Medicaid? How often is Medicaid billed? Policies and procedures regarding Medicaid receipts, i.e., where are payments received, who reconciles payments, who supervises payments, etc. The Carolinas Center Page 2 of 2