10-16 FORM CMS (Cont.)

Transcription

1 Attachment A New Hospice Medicare Cost Report Schedules

2 10-16 FORM CMS (Cont.) HOME HEALTH AGENCY REIMBURSEMENT PROVIDER CCN: PERIOD: WORKSHEET S-2-1 QUESTIONNAIRE FROM: FROM: TO: General Instruction: For all column 1 responses, enter "Y" for YES of "N" for NO Enter all dates in the format (mm/dd/yyyy) COMPLETED BY ALL HHAs Y/N Date V/I Provider Organization and Operation Has the HHA changed ownership immediately prior to the beginning of the cost reporting period? 1 If column 1 is yes, enter the date of the change in column 2. (see instructions) 2 Has the HHA terminated participation in the Medicare program? If column 1 is yes, enter in column 2 the date 2 of termination and in column 3, "V" for voluntary or "I" for involuntary. (see instructions) 3 Is the HHA involved in business transactions, including management contracts, with individuals or entities 3 (e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical staff, management personnel, or members of the board of directors through ownership, control, or family and other similar relationships? (see instructions) Y/N Type Date Financial Data and Reports Column 1: Were the financial statements prepared by a Certified Public Accountant? 4 Column 2: If column 1 is yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter date available in column 3. (see instructions) If no, see instructions. 5 Are the cost report total expenses and total revenues different from those on the filed financial statements? 5 Enter "Y" for yes or "N" for no in column 1. If yes, submit reconciliation. Bad Debts Y/N 6 Is the HHA or HHA-based entities seeking reimbursement for bad debts? If yes, see instructions. 6 7 If line 6 is yes, did the HHA's bad debt collection policy change during this cost reporting period? If yes, submit copy. 7 8 If line 6 is yes, were patient coinsurance amounts waived? If yes, see instructions. 8 Y/N Date PS&R Report Data Was the cost report prepared using the PS&R Report only? If column 1 is yes, enter the 9 paid-through date of the PS&R Report used in column 2. (see instructions) 10 Was the cost report prepared using the PS&R Report for totals and the HHA's records for allocation? 10 If column 1 is yes, enter the paid-through date in column 2. (see instructions) 11 If line 9 or 10 is yes, were adjustments made to PS&R Report data for additional claims that have been 11 billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions. 12 If line 9 or 10 is yes, were adjustments made to PS&R Report data for corrections of other 12 PS&R Report information? If yes, see instructions. 13 If line 9 or 10 is yes, were adjustments made to PS&R Report data for Other? 13 Describe the other adjustments: 14 Was the cost report prepared only using the HHA's records? If yes, see instructions. 14 Cost Report Preparer Contact Information 15 First name: Last name: Title: Employer: Phone number: Address: 17 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION ) Rev

3 3290 (Cont.) FORM CMS PROVIDER CCN: PERIOD: HHA-BASED HOSPICE IDENTIFICATION DATA FROM: WORKSHEET S-5 HOSPICE CCN: TO: PART I - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015 Title XVIII Total Unduplicated Unduplicated Skilled Other Days Unduplicated Nursing Unduplicated (sum of Enrollment Days Days Facility Days Days cols. 1 & 3) Hospice Continuous Home Care 1 2 Hospice Routine Home Care 2 3 Hospice Inpatient Respite Care 3 4 Hospice General Inpatient Care 4 5 Total Hospice Days 5 PART II - CENSUS DATA FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, 2015 Title XVIII Skilled Total Nursing (sum of Census Data Title XVIII Facility Other cols. 1 & 3) Number of Patients Receiving 6 Hospice Care 7 Total Number of Unduplicated 7 Continuous Care Hours Billable to Medicare 8 Average Length of Stay (line 5 divided by line 6) 8 9 Unduplicated Census Count 9 NOTE: Parts I & II, column 1 also includes the days reported in column 2. PART III - ENROLLMENT DAYS FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015 Unduplicated Days Title XVIII Title XIX Medicare Medicaid Other Total Hospice Continuous Home Care Hospice Routine Home Care Hospice Inpatient Respite Care Hospice General Inpatient Care Total Hospice Days 14 PART IV - CONTRACTED STATISTICAL DATA FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2015 Title XVIII Title XIX Medicare Medicaid Other Total Hospice Inpatient Respite Care Hospice General Inpatient Care 16 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS THROUGH ) Rev. 17

4 3290 (Cont.) FORM CMS ANALYSIS OF HHA-BASED HOSPICE COSTS PROVIDER CCN: PERIOD: WORKSHEET O FROM: HOSPICE CCN: TO: SUBTOTAL (col. 1 plus RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 2) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) GENERAL SERVICE COST CENTERS Cap Rel Costs-Bldg & Fixt* Cap Rel Costs-Mvble Equip* Employee Benefits Department* Administrative & General * Plant Operation & Maintenance* Laundry & Linen Service* Housekeeping* Dietary* Nursing Administration* Routine Medical Supplies* Medical Records* Staff Transportation* Volunteer Service Coordination* Pharmacy* Physician Administrative Services* Other General Service* Patient/Residential Care Services 17 DIRECT PATIENT CARE SERVICE COST CENTERS Inpatient Care-Contracted** Physician Services** Nurse Practitioner** Registered Nurse** LPN/LVN** Physical Therapy** Occupational Therapy** Speech/ Language Pathology** Medical Social Services** Spiritual Counseling** Dietary Counseling** Counseling - Other** Hospice Aide & Homemaker Services** Durable Medical Equipment/Oxygen** Patient Transportation** 39 * Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate. ** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5. FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3247) Rev. 17

5 10-16 FORM CMS (Cont.) ANALYSIS OF HHA-BASED HOSPICE COSTS PROVIDER CCN: PERIOD: WORKSHEET O FROM: HOSPICE CCN: TO: TOTAL (col. 1 through RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 5) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.) Imaging Services** Labs & Diagnostics** Medical Supplies-Non-routine** Outpatient Services** Palliative Radiation Therapy** Palliative Chemotherapy** Other Patient Care Services** 46 NONREIMBURSABLE COST CENTERS Bereavement Program * Volunteer Program * Fundraising* Hospice/Palliative Medicine Fellows* Palliative Care Program* Other Physician Services* Residential Care * Advertising* Telehealth/Telemonitoring* Thrift Store* Nursing Facility Room & Board* Other Nonreimbursable* Total 100 * Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate. ** See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5. FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3247) Rev

6 3290 (Cont.) FORM CMS ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE CONTINUOUS HOME CARE PROVIDER CCN: PERIOD: WORKSHEET O-1 FROM: FROM: HOSPICE CCN: TO: SUBTOTAL ( col. 1 plus RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 2 ) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) DIRECT PATIENT CARE SERVICE COST CENTERS 25 Inpatient Care - Contracted Physician Services Nurse Practitioner Registered Nurse LPN/LVN Physical Therapy Occupational Therapy Speech/ Language Pathology Medical Social Services Spiritual Counseling Dietary Counseling Counseling - Other Hospice Aide and Homemaker Services Durable Medical Equipment/Oxygen Patient Transportation Imaging Services Labs and Diagnostics Medical Supplies-Non-routine Outpatient Services Palliative Radiation Therapy Palliative Chemotherapy Other Patient Care Services Total * 100 * Transfer the amount in column 7 to Wkst. O-5, column 1, line 50. FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248) Rev. 17

7 10-16 FORM CMS (Cont.) ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE ROUTINE HOME CARE PROVIDER CCN: PERIOD: WORKSHEET O-2 FROM: FROM: HOSPICE CCN: TO: SUBTOTAL (col. 1 plus RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 2) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) DIRECT PATIENT CARE SERVICE COST CENTERS 25 Inpatient Care - Contracted Physician Services Nurse Practitioner Registered Nurse LPN/LVN Physical Therapy Occupational Therapy Speech/ Language Pathology Medical Social Services Spiritual Counseling Dietary Counseling Counseling - Other Hospice Aide and Homemaker Services Durable Medical Equipment/Oxygen Patient Transportation Imaging Services Labs and Diagnostics Medical Supplies-Non-routine Outpatient Services Palliative Radiation Therapy Palliative Chemotherapy Other Patient Care Services Total * 100 * Transfer the amount in column 7 to Wkst. O-5, column 1, line 51 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248) Rev

8 3290 (Cont.) FORM CMS '10-16 ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE INPATIENT RESPITE CARE PROVIDER CCN: PERIOD: WORKSHEET O-3 FROM: FROM: HOSPICE CCN: TO: SUBTOTAL (col. 1 plus RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 2) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) DIRECT PATIENT CARE SERVICE COST CENTERS 25 Inpatient Care - Contracted Physician Services Nurse Practitioner Registered Nurse LPN/LVN Physical Therapy Occupational Therapy Speech/ Language Pathology Medical Social Services Spiritual Counseling Dietary Counseling Counseling - Other Hospice Aide and Homemaker Services Durable Medical Equipment/Oxygen Patient Transportation Imaging Services Labs and Diagnostics Medical Supplies-Non-routine Outpatient Services Palliative Radiation Therapy Palliative Chemotherapy Other Patient Care Services Total * 100 * Transfer the amount in column 7 to Wkst. O-5, column 1, line 52 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248) Rev. 17

9 10-16 FORM CMS (Cont.) ANALYSIS OF HHA-BASED HOSPICE COSTS FOR HOSPICE GENERAL INPATIENT CARE PROVIDER CCN: PERIOD: WORKSHEET O-4 FROM: FROM: HOSPICE CCN: TO: SUBTOTAL (col. 1 plus RECLASSI- ADJUST- TOTAL SALARIES OTHER col. 2) FICATIONS SUBTOTAL MENTS (col. 5 ± col. 6) DIRECT PATIENT CARE SERVICE COST CENTERS 25 Inpatient Care - Contracted Physician Services Nurse Practitioner Registered Nurse LPN/LVN Physical Therapy Occupational Therapy Speech/ Language Pathology Medical Social Services Spiritual Counseling Dietary Counseling Counseling - Other Hospice Aide and Homemaker Services Durable Medical Equipment/Oxygen Patient Transportation Imaging Services Labs and Diagnostics Medical Supplies-Non-routine Outpatient Services Palliative Radiation Therapy Palliative Chemotherapy Other Patient Care Services Total * 100 * Transfer the amount in column 7 to Wkst. O-5, column 1, line 53 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3248) Rev

10 3290 (Cont.) FORM CMS '10-16 COST ALLOCATION - DETERMINATION OF HHA-BASED HOSPICE PROVIDER CCN: PERIOD: WORKSHEET O-5 NET EXPENSES FOR ALLOCATION FROM: FROM: HOSPICE CCN: TO: GENERAL HOSPICE SERVICE DIRECT EXPENSES TOTAL EXPENSES FROM WKST B EXPENSES (see instructions) (see instructions) (sum of cols ) Descriptions GENERAL SERVICE COST CENTERS 1 Cap Rel Costs-Bldg & Fixt 1 2 Cap Rel Costs-Mvble Equip 2 3 Employee Benefits Department 3 4 Administrative & General 4 5 Plant Operation & Maintenance 5 6 Laundry & Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Routine Medical Supplies Medical Records Staff Transportation Volunteer Service Coordination Pharmacy Physician Administrative Services Other General Service Patient/Residential Care Services 17 LEVEL OF CARE 50 Hospice Continuous Home Care Hospice Routine Home Care Hospice Inpatient Respite Care Hospice General Inpatient Care 53 NONREIMBURSABLE COST CENTERS 60 Bereavement Program Volunteer Program Fundraising Hospice/Palliative Medicine Fellows Palliative Care Program Other Physician Services Residential Care Advertising Telehealth/Telemonitoring Thrift Store Nursing Facility Room & Board Other Nonreimbursable Negative Cost Center Total 100 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3249) Rev. 17

11 '10-16 FORM CMS (Cont.) COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS PROVIDER CCN: PERIOD: WORKSHEET O-6 HOSPICE CCN: FROM: FROM: PART I TO: CAP REL CAP REL EMPLOYEE ADMINIS- PLANT LAUNDRY HOUSE- DIETARY TOTAL BLDG MVBLE BENEFITS TRATIVE & OP & & LINEN KEEPING EXPENSES & FIX EQUIP DEPARTMENT SUBTOTAL GENERAL MAINT A GENERAL SERVICE COST CENTERS 1 Cap Rel Costs-Bldg & Fixt 1 2 Cap Rel Costs-Mvble Equip 2 3 Employee Benefits Department 3 4 Administrative & General 4 5 Plant Operation & Maintenance 5 6 Laundry & Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Routine Medical Supplies Medical Records Staff Transportation Volunteer Service Coordination Pharmacy Physician Administrative Services Other General Service Patient/Residential Care Services 17 LEVEL OF CARE 50 Hospice Continuous Home Care Hospice Routine Home Care Hospice Inpatient Respite Care Hospice General Inpatient Care 53 NONREIMBURSABLE COST CENTERS 60 Bereavement Program Volunteer Program Fundraising Hospice/Palliative Medicine Fellows Palliative Care Program Other Physician Services Residential Care Advertising Telehealth/Telemonitoring Thrift Store Nursing Facility Room & Board Other Nonreimbursable Negative Cost Center Total 100 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250) Rev

12 4090 (Cont.) FORM CMS COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS PROVIDER CCN: PERIOD: WORKSHEET O-6 HOSPICE CCN: FROM: PART I TO: NURSING ROUTINE MEDICAL STAFF VOLUNTEER PHARMACY PHYSICIAN OTHER PATIENT / TOTAL ADMINIS- MEDICAL RECORDS TRANS- SVC COOR- ADMINISTRA- GENERAL RESIDENTIAL TRATION SUPPLIES PORTATION DINATION TIVE SVCS SERVICE CARE SVCS Descriptions GENERAL SERVICE COST CENTERS 1 Cap Rel Costs-Bldg & Fixt 1 2 Cap Rel Costs-Mvble Equip 2 3 Employee Benefits Department 3 4 Administrative & General 4 5 Plant Operation & Maintenance 5 6 Laundry & Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Routine Medical Supplies Medical Records Staff Transportation Volunteer Service Coordination Pharmacy Physician Administrative Services Other General Service Patient/Residential Care Services 17 LEVEL OF CARE 50 Continuous Home Care Routine Home Care Inpatient Respite Care General Inpatient Care 53 NONREIMBURSABLE COST CENTERS 60 Bereavement Program Volunteer Program Fundraising Hospice/Palliative Medicine Fellows Palliative Care Program Other Physician Services Residential Care Advertising Telehealth/Telemonitoring Thrift Store Nursing Facility Room & Board Other Nonreimbursable Negative Cost Center Total 100 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250) Rev.17

13 10-16 FORM CMS (Cont.) COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS PROVIDER CCN: PERIOD: WORKSHEET O-6 HOSPICE CCN: FROM: FROM: PART II TO: CAP REL CAP REL EMPLOYEE ADMINIS- PLANT LAUNDRY HOUSE- DIETARY BLDG MVBLE BENEFITS TRATIVE & OP & & LINEN KEEPING & FIX EQUIP DEPARTMENT GENERAL MAINT ( Square ( Dollar ( Gross RECONCIL- ( Accum. ( Square ( In-Facility ( Square ( In-Facility Feet ) Value ) Salaries ) IATION Cost ) Feet ) Days ) Feet ) Days ) Cost Center Descriptions A GENERAL SERVICE COST CENTERS 1 Cap Rel Costs-Bldg & Fixt 1 2 Cap Rel Costs-Mvble Equip 2 3 Employee Benefits Department 3 4 Administrative & General 4 5 Plant Operation & Maintenance 5 6 Laundry & Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Routine Medical Supplies Medical Records Staff Transportation Volunteer Service Coordination Pharmacy Physician Administrative Services Other General Service Patient/Residential Care Services 17 LEVEL OF CARE 50 Hospice Continuous Home Care Hospice Routine Home Care Hospice Inpatient Respite Care Hospice General Inpatient Care 53 NONREIMBURSABLE COST CENTERS 60 Bereavement Program Volunteer Program Fundraising Hospice/Palliative Medicine Fellows Palliative Care Program Other Physician Services Residential Care Advertising Telehealth/Telemonitoring Thrift Store Nursing Facility Room & Board Other Nonreimbursable Negative Cost Center Cost to be allocated (per Wkst. O-6, Part I) Unit cost multiplier 102 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250) Rev

14 3290 (Cont.) FORM CMS COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS STATISTICAL BASIS PROVIDER CCN: PERIOD: WORKSHEET O-6 HOSPICE CCN: FROM PART II TO NURSING ROUTINE MEDICAL STAFF VOLUNTEER PHARMACY PHYSICIAN OTHER PATIENT / ADMINIS- MEDICAL RECORDS TRANS- SVC COOR- ADMINISTRA- GENERAL RESIDENTIAL TRATION SUPPLIES PORTATION DINATION TIVE SVCS SERVICE CARE SVCS ( Direct ( Patient ( Patient ( Hours of ( Patient ( Specify ( In-Facility Nurs. Hrs. ) Days ) Days ) ( Mileage ) Service ) ( Charges ) Days ) Basis ) Days ) TOTAL Cost Center Descriptions GENERAL SERVICE COST CENTERS 1 Cap Rel Costs-Bldg & Fixt 1 2 Cap Rel Costs-Mvble Equip 2 3 Employee Benefits Department 3 4 Administrative & General 4 5 Plant Operation & Maintenance 5 6 Laundry & Linen Service 6 7 Housekeeping 7 8 Dietary 8 9 Nursing Administration 9 10 Routine Medical Supplies Medical Records Staff Transportation Volunteer Service Coordination Pharmacy Physician Administrative Services Other General Service Patient/Residential Care Services 17 LEVEL OF CARE 50 Continuous Home Care Routine Home Care Inpatient Respite Care General Inpatient Care 53 NONREIMBURSABLE COST CENTERS 60 Bereavement Program Volunteer Program Fundraising Hospice/Palliative Medicine Fellows Palliative Care Program Other Physician Services Residential Care Advertising Telehealth/Telemonitoring Thrift Store Nursing Facility Room & Board Other Nonreimbursable Negative Cost Center Cost to be allocated (per Wkst. O-6, Part I) Unit cost multiplier 102 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3250) Rev. 17

15 10-16 FORM CMS (Cont.) APPORTIONMENT OF HHA-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE PROVIDER CCN: PERIOD: WORKSHEET O-7 FROM: HOSPICE CCN: FROM: TO: Total HHA Wkst. B, Charges Cost to Charges by LOC (from Provider Records) Shared Service Costs by LOC col. 6, Total HHA (from Provider Charge HCHC HRHC HIRC HGIP line Costs Records) Ratio HCHC HRHC HIRC HGIP col. 3 x col. 4 (col. 3 x col. 5) (col. 3 x col. 6) (col. 3 x col. 7) Cost Center Descriptions ANCILLARY SERVICE COST CENTERS 1 Physical Therapy Occupational Therapy Speech/ Language Pathology Medical Social Services - Direct Medical Supplies Durable Medical Equipment/Oxygen Totals (sum of lines 1-7) 7 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3251) Rev

16 3290 (Cont.) FORM CMS CALCULATION OF HHA-BASED HOSPICE PER DIEM COST PROVIDER CCN: PERIOD: WORKSHEET O-8 FROM: HOSPICE CCN: TO: TITLE XVIII TITLE XIX MEDICARE MEDICAID TOTAL HOSPICE CONTINUOUS HOME CARE 1 Total cost (Wkst. O-6, Part I, col. 18, line 50 plus Wkst. O-7, col. 8, line 7) 1 2 Total unduplicated days (Wkst. S-5, col. 4, line 10) 2 3 Total average cost per diem (line 1 divided by line 2) 3 4 Unduplicated program days (Wkst. S-5 col. as appropriate, line 10) 4 5 Program cost (line 3 times line 4) 5 HOSPICE ROUTINE HOME CARE 6 Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 9, line 7) 6 7 Total unduplicated days (Wkst. S-5, col. 4, line 11) 7 8 Total average cost per diem (line 6 divided by line 7) 8 9 Unduplicated program days (Wkst. S-5, col. as appropriate, line 11) 9 10 Program cost (line 8 times line 9) 10 HOSPICE INPATIENT RESPITE CARE 11 Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 10, line 7) Total unduplicated days (Wkst. S-5, col. 4, line 12) Total average cost per diem (line 11 divided by line 12) Unduplicated program days (Wkst. S-5, col. as appropriate, line 12) Program cost (line 13 times line 14) 15 HOSPICE GENERAL INPATIENT CARE 16 Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 11, line 7) Total unduplicated days (Wkst. S-5, col. 4, line 13) Total average cost per diem (line 16 divided by line 17) Unduplicated program days (Wkst. S-5, col. as appropriate, line 13) Program cost (line 18 times line 19) 20 TOTAL HOSPICE CARE 21 Total cost (sum of line 1 + line 6 + line 11 + line 16) Total unduplicated days (Wkst. S-5, col. 4, line 14) Average cost per diem (line 21 divided by line 22) 23 FORM CMS (10/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3252) Rev. 17

17 Attachment B Sample Hospice Chart of Accounts

18 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION CURRENT ASSETS Checking account Payroll account Savings account Petty cash Accounts receivable - Medicare Accounts receivable - Medicaid Accounts receivable - Medicaid R&B Accounts receivable - Private Allowance for bad debts Allowance for contractual adjustments-medicare Allowance for contractual adjustments-medicaid Allowance for contractual adjustments-other Notes receivable Due from Medicare Employee advances Other receivables Due from stockholder Accrued interest receivable Prepaid Insurance Prepaid Expenses PROPERTY AND EQUIPMENT Land Buildings Accum depreciation - Building Building Improvements Accum depreciation - Bldg improvements Leasehold improvements Accum depreciation - Leasehold improvements Equipment Accum depreciation - Equipment Furniture and fixtures Accum depreciation - Furniture and fixtures Vehicles Accum depreciation - Vehicles Page 1 of 10

19 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION OTHER ASSETS Security deposits Goodwill Accum amortization - Goodwill Other intangible assets Accum amortization - other intangibles CURRENT LIABILITIES Accounts payable Accounts payable - Medicaid R&B Current maturities of long-term debt Notes payable Due to stockholder Accrued salaries Accrued vacation pay Accrued pension payable Accrued property taxes payable Accrued other Accrued interest payable Federal withholding tax payable FICA withholding tax payable State withholding tax payable Local withholding tax payable Accrued FUTA Accrued SUTA Employee health insurance payable Employee garnishments LONG-TERM LIABILITIES Long-term notes payable Capitalized lease obligations STOCKHOLDERS' EQUITY Common Stock Additional paid in capital Retained earnings Page 2 of 10

20 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION REVENUE Medicare - Routine Medicare - Continuous Care Medicare - I/P Respite Medicare - GIP Medicaid - Routine Medicaid - Continuous Care Medicaid - I/P Respite Medicaid - GIP Medicaid - Room & Board Private Pay - Routine Private Pay - Continuous Care Private Pay - I/P Respite Private Pay - GIP Palliative physician services Palliative other services Other physician services Residential revenue Contractual adjustments - Medicare Contractual adjustments - Medicaid Contractual adjustments - Other EXPENSES Other income Salaries - administrator Salaries - office and clerical Salaries - human resources Salaries - maintenance Salaries - housekeeping Salaries - dietary Salaries - housekeeping Salaries - medical records Salaries - nursing administration Salaries - Volunteer coordinator Salaries - physician (general) Salaries - physician (administrative) Salaries - physician (routine) Salaries - physician (continuous) Salaries - physician (I/P respite) Salaries - physician (GIP) Salaries - physician (palliative care) Page 3 of 10

21 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Salaries - physician (other services) Salaries - nurse practitioner (general) Salaries - nurse practitioner (routine) Salaries - nurse practitioner (continuous) Salaries - nurse practitioner (I/P respite) Salaries - nurse practitioner (GIP) Salaries - nurse practitioner (palliative care) Salaries - registered nurses (general) Salaries - registered nurses (routine) Salaries - registered nurses (continuous) Salaries - registered nurses (I/P respite) Salaries - registered nurses (GIP) Salaries - registered nurses (palliative care) Salaries - LPN/LVNs (general) Salaries - LPN/LVNs (routine) Salaries - LPN/LVNs (continuous) Salaries - LPN/LVNs (I/P respite) Salaries - LPN/LVNs (GIP) Salaries - LPN/LVNs (palliative care) Salaries - physical therapy (general) Salaries - physical therapy (routine) Salaries - physical therapy (continuous) Salaries - physical therapy (I/P respite) Salaries - physical therapy (GIP) Salaries - physical therapy (palliative care) Salaries - occupational therapy (general) Salaries - occupational therapy (routine) Salaries - occupational therapy (continuous) Salaries - occupational therapy (I/P respite) Salaries - occupational therapy (GIP) Salaries - occupational therapy (palliative care) Salaries - speech therapy (general) Salaries - speech therapy (routine) Salaries - speech therapy (continuous) Salaries - speech therapy (I/P respite) Salaries - speech therapy (GIP) Salaries - speech therapy (palliative care) Salaries - medical social services (general) Salaries - medical social services (routine) Salaries - medical social services (continuous) Salaries - medical social services (I/P respite) Salaries - medical social services (GIP) Salaries - medical social services (palliative care) Salaries - spiritual counseling (general) Salaries - spiritual counseling (routine) Salaries - spiritual counseling (continuous) Salaries - spiritual counseling (I/P respite) Salaries - spiritual counseling (GIP) Page 4 of 10

22 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Salaries - spiritual counseling (palliative care) Salaries - dietary counseling (general) Salaries - dietary counseling (routine) Salaries - dietary counseling (continuous) Salaries - dietary counseling (I/P respite) Salaries - dietary counseling (GIP) Salaries - dietary counseling (palliative care) Salaries - other counseling (general) Salaries - other counseling (routine) Salaries - other counseling (continuous) Salaries - other counseling (I/P respite) Salaries - other counseling (GIP) Salaries - other counseling (palliative care) Salaries - Aide and homemaker (general) Salaries - Aide and homemaker (routine) Salaries - Aide and homemaker (continuous) Salaries - Aide and homemaker (I/P respite) Salaries - Aide and homemaker (GIP) Salaries - Aide and homemaker (palliative care) Salaries - Bereavement program Salaries - Volunteer program Salaries - Residential care Payroll taxes Workers' compensation Health insurance Pension Other benefits Travel - administrative Travel - physician (general) Travel - physician (administrative) Travel - physician (routine) Travel - physician (continuous) Travel - physician (I/P respite) Travel - physician (GIP) Travel - physician (palliative care) Travel - physician (other services) Travel - nurse practitioner (general) Travel - nurse practitioner (routine) Travel - nurse practitioner (continuous) Travel - nurse practitioner (I/P respite) Travel - nurse practitioner (GIP) Travel - nurse practitioner (palliative care) Travel - registered nurses (general) Travel - registered nurses (routine) Travel - registered nurses (continuous) Travel - registered nurses (I/P respite) Page 5 of 10

23 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Travel - registered nurses (GIP) Travel - registered nurses (palliative care) Travel - LPN/LVNs (general) Travel - LPN/LVNs (routine) Travel - LPN/LVNs (continuous) Travel - LPN/LVNs (I/P respite) Travel - LPN/LVNs (GIP) Travel - LPN/LVNs (palliative care) Travel - physical therapy (general) Travel - physical therapy (routine) Travel - physical therapy (continuous) Travel - physical therapy (I/P respite) Travel - physical therapy (GIP) Travel - physical therapy (palliative care) Travel - occupational therapy (general) Travel - occupational therapy (routine) Travel - occupational therapy (continuous) Travel - occupational therapy (I/P respite) Travel - occupational therapy (GIP) Travel - occupational therapy (palliative care) Travel - speech therapy (general) Travel - speech therapy (routine) Travel - speech therapy (continuous) Travel - speech therapy (I/P respite) Travel - speech therapy (GIP) Travel - speech therapy (palliative care) Travel - medical social services (general) Travel - medical social services (routine) Travel - medical social services (continuous) Travel - medical social services (I/P respite) Travel - medical social services (GIP) Travel - medical social services (palliative care) Travel - spiritual counseling (general) Travel - spiritual counseling (routine) Travel - spiritual counseling (continuous) Travel - spiritual counseling (I/P respite) Travel - spiritual counseling (GIP) Travel - spiritual counseling (palliative care) Travel - dietary counseling (general) Travel - dietary counseling (routine) Travel - dietary counseling (continuous) Travel - dietary counseling (I/P respite) Travel - dietary counseling (GIP) Travel - dietary counseling (palliative care) Travel - other counseling (general) Travel - other counseling (routine) Travel - other counseling (continuous) Travel - other counseling (I/P respite) Page 6 of 10

24 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Travel - other counseling (GIP) Travel - other counseling (palliative care) Travel - Aide and homemaker (general) Travel - Aide and homemaker (routine) Travel - Aide and homemaker (continuous) Travel - Aide and homemaker (I/P respite) Travel - Aide and homemaker (GIP) Travel - Aide and homemaker (palliative care) Travel - Bereavement program Travel - Volunteer program Purchased services - administrative Purchased services - physician (general) Purchased services - physician (administrative) Purchased services - physician (routine) Purchased services - physician (continuous) Purchased services - physician (I/P respite) Purchased services - physician (GIP) Purchased services - physician (other services) Purchased services - registered nurses (general) Purchased services - registered nurses (routine) Purchased services - registered nurses (continuous) Purchased services - registered nurses (I/P respite) Purchased services - registered nurses (GIP) Purchased services - LPN/LVNs (general) Purchased services - LPN/LVNs (routine) Purchased services - LPN/LVNs (continuous) Purchased services - LPN/LVNs (I/P respite) Purchased services - LPN/LVNs (GIP) Purchased services - physical therapy (general) Purchased services - physical therapy (routine) Purchased services - physical therapy (continuous) Purchased services - physical therapy (I/P respite) Purchased services - physical therapy (GIP) Purchased services - speech therapy (general) Purchased services - speech therapy (routine) Purchased services - speech therapy (continuous) Purchased services - speech therapy (I/P respite) Purchased services - speech therapy (GIP) Purchased services - occupational therapy (general) Purchased services - occupational therapy (routine) Purchased services - occupational therapy (continuous) Purchased services - occupational therapy (I/P respite) Purchased services - occupational therapy (GIP) Purchased services - medical social services (general) Purchased services - medical social services (routine) Purchased services - medical social services (continuous) Purchased services - medical social services (I/P respite) Page 7 of 10

25 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Purchased services - medical social services (GIP) Purchased services - spiritual counseling (general) Purchased services - spiritual counseling (routine) Purchased services - spiritual counseling (continuous) Purchased services - spiritual counseling (I/P respite) Purchased services - spiritual counseling (GIP) Purchased services - dietary counseling (general) Purchased services - dietary counseling (routine) Purchased services - dietary counseling (continuous) Purchased services - dietary counseling (I/P respite) Purchased services - dietary counseling (GIP) Purchased services - other counseling (general) Purchased services - other counseling (routine) Purchased services - other counseling (continuous) Purchased services - other counseling (I/P respite) Purchased services - other counseling (GIP) Purchased services - Aide and homemaker (general) Purchased services - Aide and homemaker (routine) Purchased services - Aide and homemaker (continuous) Purchased services - Aide and homemaker (I/P respite) Purchased services - Aide and homemaker (GIP) Inpatient - general inpatient care Inpatient - respite care Contract - nursing home R&B Pharmacy Infusion therapy (routine) Infusion therapy (continuous) Infusion therapy (I/P respite) Infusion therapy (GIP) Infusion therapy (palliative care) Durable medical equipment/oxygen (routine) Durable medical equipment/oxygen (continuous) Durable medical equipment/oxygen (I/P respite) Durable medical equipment/oxygen (GIP) Durable medical equipment/oxygen (palliative care) Patient transportation (routine) Patient transportation (continuous) Patient transportation (I/P respite) Patient transportation (GIP) Patient transportation (palliative care) Imaging services (routine) Imaging services (continuous) Imaging services (I/P respite) Imaging services (GIP) Imaging services (palliative care) Labs and diagnostics (routine) Labs and diagnostics (continuous) Page 8 of 10

26 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Labs and diagnostics (I/P respite) Labs and diagnostics (GIP) Labs and diagnostics (palliative care) Medical supplies (routine) Medical supplies (continuous) Medical supplies (I/P respite) Medical supplies (GIP) Medical supplies (palliative care) Outpatient services (routine) Outpatient services (continuous) Outpatient services (I/P respite) Outpatient services (GIP) Outpatient services (palliative care) Radiation therapy (routine) Radiation therapy (continuous) Radiation therapy (I/P respite) Radiation therapy (GIP) Radiation therapy (palliative care) Chemotherapy (routine) Chemotherapy (continuous) Chemotherapy (I/P respite) Chemotherapy (GIP) Chemotherapy (palliative care) Other service costs (routine) Other service costs (continuous) Other service costs (I/P respite) Other service costs (GIP) Other service costs (palliative care) Bereavement program costs Volunteer program costs Fundraising Other program costs Office rent Equipment rent Utilities Repairs and maintenance Building and contents insurance Vehicle fuel Telephone Postage Printing Office supplies Legal and accounting Dues and subscriptions Insurance Meals and entertainment Page 9 of 10

27 SAMPLE HOSPICE CHART OF ACCOUNTS ACCOUNT NUMBER ACCOUNT DESCRIPTION Meetings and conferences Advertising - Help wanted ads Advertising - yellow pages ads Advertising - public relations Contributions Bank service charges Fines and penalties Taxes and licenses Minor equipment Miscellaneous expense Interest expense Depreciation expense - building & fixtures Depreciation expense - moveable equipment Depreciation expense - vehicles Amortization expense Provision for bad debts OTHER (INCOME) EXPENSE Gain (loss) on sale of equipment Interest income Contributions Fundraising Other income INCOME TAXES Provision for income taxes Page 10 of 10

28 Attachment C Hospice Cost Report Recommendations Letter

29 September 30, 2016 Susan M. Burris, Director Division of Cost Reporting Chronic Care Policy Group Center for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Deanna Rhodes, Deputy Director Division of Cost Reporting Chronic Care Policy Group Center for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Dear Ms. Burris and Ms. Rhodes: Since 2009, representatives of the National Association for Home Care & Hospice s (NAHC s) Home Care and Hospice Financial Managers Association (HHFMA) and Hospice Association of America (HAA) have worked with the Centers for Medicare & Medicaid Services (CMS ) Division of Cost Reporting to support and recommend revisions to the hospice cost report with the goal of ensuring that the hospice cost report supplies data that is more accurate, more thorough, and better represents actual costs incurred in the delivery of hospice care. These efforts began with development of a white paper that contained recommendations for hospice cost report changes and a subsequent face-to-face meeting with your department. Over more recent years, NAHC and its member agencies and consultants submitted detailed comments on the cost reporting changes that CMS promulgated through the notice and comment process for freestanding, hospital-based, home health-based, and skilled nursing facility-based hospices. On August 29, 2014, CMS released the new cost report requirements for freestanding hospice organizations in final form. As a result, freestanding hospices no longer complete the Form CMS , but rather must complete and submit the Hospice Cost Report, Form CMS The implementation date for the new cost report for freestanding hospices was cost reporting periods beginning on or after October 1, P age

30 As of May 31, 2016, the majority of freestanding hospice providers have completed and submitted a cost report utilizing CMS The process has supplied considerable insight into challenges that may impact the quality of data supplied via the hospice cost report. In the weeks following the May 31 deadline, representatives of the HHFMA Payment and Reimbursement Committee, NAHC staff, and others met to discuss their experiences and perspectives on the cost reporting process under the new Form CMS What follows is a series of issues and recommendations that the group has, collectively, identified. In almost all cases, these concerns are applicable to the revised provider-based hospice cost reporting requirements, as well. Additionally, we have included additional issues that are not directly related to the cost report changes but are appropriate to the discussion generally. Our intent in bringing these issues to you is to encourage appropriate modifications to the hospice cost reporting and review process at the earliest possible opportunity. Special thanks go to the following individuals for their contributions to this effort: Mark P. Sharp, CPA, BKD LLP, Chairman, HHFMA Board of Directors Dave Macke, CHFP, FHFMA, Von Lehman CPA and Advisory Firm, and Chair, HHFMA Payment and Reimbursement Committee Thomas Boyd, MBA, CFE, CHFP, Simione Healthcare Consultants, LLC Ted Cuppett, CPA, The Health Group, LLC Tony James, Hospice Compassus Maureen Laskowski, Simione Healthcare Consultants, LLC Gary R. Massey, CPA, CliftonLarsonAllen LLP Emmy Nteziryayo, Hospice Compassus BACKGROUND Form CMS represents a substantial expansion in comparison with previously required cost reports. The cost report requires submission of significantly expanded financial information, statistics used in the cost finding process, and the ultimate determination of costs by level of care ( LOC ). NAHC, other national and state associations, and industry consultants provided significant educational opportunities for hospices and cost report preparers to assist in guiding them in preparing for and completing the cost report. Form CMS represents a significant improvement in the information available to CMS and the respective hospices regarding their operating activities; however, the quality of the information available to both CMS and the hospice is dependent on the quality of the cost report submission. NAHC is pleased to provide the following narrative, comments, and recommendations to CMS for purposes of continued enhancement to the Hospice Cost & Data Report and improvement in the quality of the cost report submissions. We are hopeful that the information provided herein is useful to CMS as it continues to move forward in securing quality information that can be used to better assess hospice costs and modifying hospice reimbursement. Certain discussion points raised in this letter relate to technical corrections that could be easily implemented; however, we recognize that other discussion points are more complicated in nature and implementation. The issues raised in this letter would have similar applicability to the Worksheet O Series (hospice worksheets) contained in other providers cost reports effective for years beginning on or after October 1, P age

31 COST REPORT EDITS Medicare cost reports submitted electronically must meet a variety of edits. These include mathematical accuracy edits, certain minimum file requirements, and other data edits. The edits are applied at two levels. Level I edits test the format of the data to identify error conditions that must be corrected or they will result in a cost report rejection. Level II edits identify potential inconsistencies and missing data items. These items should be resolved at the hospice site and supporting documentation (such as worksheets or data) should be submitted with the cost report. The Level 1 edits that were incorporated into the cost report required the reporting of certain information believed to be of assistance in securing more comprehensive information. When the Hospice Cost & Data Report was being modified, numerous Level I edits were proposed that would have substantially improved the quality of cost report submissions. The following were originally proposed to be Level I edits; however, when the final version of the cost report was released they were moved to Level II edits: There must be an entry on Worksheet A, column 7, lines 3, 4, 5, 13, 14, 28, 37, 38, and 41. These lines represent the following cost centers: Line 3 Employee Benefits Department Line 4 Administrative & General Line 5 Plant Operations and Maintenance Line 13 Volunteer Service Coordination Line 14 Pharmacy Line 28 Registered Nurse Line 37 Hospice Aide and Homemaker Service Line 38 Durable Medical Equipment/Oxygen Line 41 Labs and Diagnostics We recommend that these edits be modified as originally proposed to Level I edits, except for Line 5 Plant Operations and Maintenance. Certain providers may have a lease arrangement whereby operation and maintenance costs are included in the space rental (lease agreement) and, accordingly, there are no costs segregated which would be reported on Line 5. The required entry into these lines (Line 3, 4, 13, 14, 28, 37, 38, and 41) should cause an improvement in the cost report information received. Inasmuch as the cost report must cover between one (1) month and thirteen (13) months, all hospices should be reporting costs in these cost centers. Furthermore, we recommend that Line 1 Capital Related Costs Building and Fixtures and Line 33 Medical Social Services be added to the list of lines that require cost reporting to avoid a Level I error from being generated. 3 P age

32 Lastly, we recommend that a Level I edit be generated if costs are reported on Worksheet A, column 7, line 70 and no revenues have been reported on Worksheet F-2, column 2, line 10 and vice versa. CONTRACTED INPATIENT COSTS AND COST REPORT ELECTRONIC REQUIREMENTS Cost report instructions provide that when a hospice contracts for IRC (Inpatient Respite Care) or GIP (General Inpatient Care) services and the contractual costs include A&G costs, the contractual costs reported on Worksheet A-3, column 7, line 25, or Worksheet A-4, column 7, line 25, may be used to reduce the accumulated cost statistic on Worksheet B-1, column 4A, line 52 or line 53, respectively. Contracted general inpatient and inpatient respite care costs include the administration conducted by the hospital, skilled nursing facility, or nursing home. Accordingly, the accumulated costs used for the allocation of administrative-general expenses on Worksheet B-1 should be reduced by the contracted general inpatient or inpatient respite care costs reported on Worksheets A-4 and A-3, respectively. Many cost report preparers are not sufficiently informed to make this statistical adjustment thereby causing inpatient respite care and general inpatient care costs to be overstated due to the over-allocation of administrative-general expenses. In order to improve the accuracy of the cost report submissions, the software vendors could automatically reduce the accumulated cost statistic by the contracted amount reported on line 25 on Worksheets A-3 and A-4. This minor software change could significantly impact the accuracy of many hospice cost reports submitted. COST REPORT TECHNICAL CORRECTION FOR DURABLE MEDICAL EQUIPMENT/OXYGEN REPORTING Line 38 on Worksheets A, A-1, A-2, A-3, and A-4 includes the costs of durable medical equipment ( DME ) and oxygen. According to the cost report instructions, as modified, hospices are to report DME/Oxygen costs by the LOC the patient was receiving at the time the DME/Oxygen was delivered. If the LOC of a patient changes after the delivery of the DME/Oxygen, the hospice may report the costs proportionally between RHC and CHC based on patient days. This guidance was very helpful to hospices. A technical problem with the cost report has been identified relating to reporting all DME/Oxygen costs. The problem relates to reporting DME/Oxygen costs as they relate to Inpatient Respite Care and General Inpatient Care. The following describes the situations: A hospice operating an inpatient unit rents oxygen and durable medical equipment to meet the needs of the patients who are being billed for inpatient respite care and general inpatient care. A hospice that places a hospice patient in a skilled nursing facility or hospital may be required to acquire oxygen or rent durable medical equipment for the particular patient who is being billed for inpatient respite care or general inpatient care. These costs should appropriately be reported on Worksheet A-3 (Inpatient Respite Care) or Worksheet A- 4 (General Inpatient Care). The cost reporting forms do not allow entry on Worksheets A-3 or A-4, Line 38 even though the hospice is tracking these costs separately in their accounting records. 4 P age

33 The inability to report these costs on Worksheet A-3 or A-4 requires the hospice to either report these expenses on Line 46 or misreport these expenses on Worksheet A-2 (Routine Home Care) thereby overstating routine home care costs and understating Inpatient Respite Care costs and/or General Inpatient Care costs. These costs can be appropriately reported by merely opening up line 38 on Worksheets A-3 and A-4 for data entry. COSTING BY LEVEL OF CARE ( LOC ); WORKSHEETS A-1, A-2, A-3, AND A-4 Very few hospice providers have systems in place that allow for direct patient care service costs to be reflected in their accounting records by level of care. Costs that are typically costed by level of care are contracted inpatient respite care costs and contracted general inpatient costs. Likewise, hospices that operate freestanding inpatient units generally segregate the costs incurred in this facility from other costs incurred by the hospice. This inability to segregate direct costs by LOC has caused hospices to reclassify costs in their accounting records using patient days, modified patient days, or other statistics. In lieu of reclassifying costs in their accounting records, many hospices reclassify costs directly in the cost report utilizing Worksheet A-6 (Reclassifications) to reclassify costs to each applicable LOC. Any direction from CMS regarding such reclassifications would be helpful to ensure improved consistency of reporting by hospices. ALLOCATION OF GENERAL SERVICE COST CENTERS Dollar Value Dollar value is the prescribed statistic for the allocation of Capital-Related Movable Equipment Costs. Based on various communications with CMS, it has been determined that a hospice that used Square Feet for the allocation of Capital-Related Movable Equipment costs on Hospice Cost & Data Report submissions prior to the required use of Form CMS can continue to use Square Feet for the allocation of these costs. Hospices that used Dollar Value in the past or new hospices submitting their first cost report are required to use Dollar Value unless approval is received from the MAC for an alternate basis in accordance with applicable rules and regulations. We appreciate CMS s efforts in regard to this matter. As follow-up to previously submitted comments, we are hopeful that CMS would consider allowing all hospices to use Dollar Value or Square Feet as an acceptable statistic similar to that option already provided to other provider types. Additionally, we request that CMS provide a definition of Dollar Value inasmuch as various definitions have been provided and no formal definition can be located in any existing CMS related guidance. Nursing Administration (Nursing Hours) We agree that the identification of Nursing Administration costs is beneficial to the ultimate determination of costs by LOC. However, the instructions to the cost report indicate that the cost of Nursing Administration is to be allocated to benefitting cost centers on the basis of Direct Nursing Hours. This cost center and the statistic are misleading and cause inappropriate costing and allocation by unsophisticated cost report preparers. 5 P age

34 We recommend that CMS consider renaming the cost center to Patient Care Administration, which would include various patient care oversight activities including Nursing Administration. Patient Care Administration would be allocated on the basis of Supervised Patient Care Hours, which would include nurses, aides, and others under the oversight of the Patient Care Administration. If Nursing Administration is retained as the name of the cost center, Supervised Patient Care Hours would still be the statistical basis, representing nurses, aides, and others under the oversight of Nursing Administration. Regardless, certain instructions to the cost report pose a problem as follows. This was extracted from comments originally submitted to the proposed rule by Simione Healthcare Consultants. The instructions are also unclear when they state that However, if the Hospice accounting system fails to specifically identify all direct nursing services to the applicable direct patient care cost center, then the salary cost of all direct nursing service is included in this cost center. This is troubling because the Medicare certified Hospice provider is required to accumulate and report accurate data; this statement implies that it is okay to not comply with the requirements. If the Hospice provider fails to keep their costs correctly in the accounting system, it is extremely likely that they also do not properly track nursing direct care hours. If all nursing costs end up on Line 9, and there is no statistic of nursing hours to allocate the cost, nothing is achieved. We recommend that CMS remove this statement from the cost report instructions as following these instructions causes significant issues in the appropriate completion of the cost report. We also recommend that CMS consider renaming the cost center and the relevant instruction to accomplish the intended objective; however, regardless of what modification are made, the ability of hospices to report all direct nursing services to Nursing Administration poses a significant threat to the quality of the cost report submission. Staff Transportation The majority of hospices track travel allowance paid to staff for the use of their personal vehicles by staff position, i.e. RN travel, PT travel, aide travel, etc. When hospices track travel allowances in this method, these travel allowances can be directly costed to the respective cost center on Worksheet A, as well as Worksheets A-1, A-2, A-3, and A-4. We recommend that instructions to the cost report provide this opportunity to hospices. Miles traveled would still be used to allocate those costs associated with owning and renting vehicles. Pharmacy Pharmacy costs have been established as a General Service Cost Center. We recommend, in keeping with comments submitted on the revisions when they were in draft form, that pharmacy costs be included on Worksheet A-1, A-2, A-3, and A-4 as a Direct Patient Care Service Cost Center. There is no doubt that these expenses are incurred for direct patient care. Hospices already generally segregate pharmacy expenses when the hospice operates a freestanding inpatient unit (similar to durable medical equipment). Establishing Pharmacy as a Direct Patient Care Service Cost Center would eliminate the need to allocate costs based on pharmacy charges to LOC on Worksheet B-1. This is a statistic that most hospices do not have available to them. Currently, hospices are creating a charge for purposes of allocating costs. Medical Supplies (Routine and Non-Routine) Hospices do not have systems that segregate medical supply costs between routine and non-routine supplies, which are separately reported on the cost report. Accordingly, hospices are reporting all medical supplies as either routine or non-routine. Due to the immaterial costs of non-routine supplies, we recommend that all supplies be reported on Worksheets A-1, 6 P age

35 A-2, A-3, and A-4 as a cost associated with direct patient care. Each hospice can determine how medical supply costs are reported by LOC. Order of Allocation The order of allocating General Service Cost Centers has generated issues relating to the overall accuracy of the costing by LOC. The most significant issues are summarized below: 1. Plant Operation and Maintenance is allocated after Administrative & General costs are allocated. This order of allocation does not allow any allocation of Plant Operation and Maintenance expenses to the Administrative & General cost center. Many hospices, especially smaller hospices, operate from a very small space and the majority of that space may be occupied to accommodate administrative activities. Excluding any ability to allocate some of these costs to the Administrative & General cost center may cause a misallocation of costs. In order to enhance the accuracy of the report, many cost report preparers have reclassified a portion of plant operation and maintenance expenses to administrative activities prior to the allocation of costs on Worksheet B. We recommend that Plant Operation and Maintenance costs be allocated prior to the allocation of Administrative & General costs. 2. Staff Transportation is presently allocated after Administration and other activities which incur transportation costs, including travel allowances paid by the hospice. As indicated below and previously discussed, the accuracy of the cost report would be significantly enhanced if the order of allocation were modified. 3. Volunteer Service Coordination is also allocated after Administrative & General costs. In some hospices, volunteers providing administrative and general support services constitute as much as 70% of all volunteer hours. Inasmuch as Volunteer Service Coordination costs cannot be allocated to the Administrative & General cost center, many preparers have reclassified a portion of Volunteer Service Coordination costs to Administrative & General on Worksheet A based on volunteer hours. The remaining Volunteer Service Coordination costs are then allocated on volunteer hours excluding those hours designated as administrative in nature. The quality of the cost report could be improved if Volunteer Service Coordination were allocated prior to Administrative & General. Our recommendation for enhancing the quality of the cost report information is that the order for allocating General Service Cost Centers be as follows. This would substantially decrease the need for cost report preparers to reclassify costs and make requests for changes in the order of allocation of General Services Cost Centers. This order of allocation is consistent with CMS Form Capital Building & Fixtures Capital Movable Equipment Employee Benefits Plant Operation & Maintenance Staff Transportation Volunteer Service Coordination Administrative & General Others as Currently Required Requests for Change in Order of Allocation and Statistical Basis Requests to make a change in the order of allocation of General Service Cost Centers and to request alternative statistical basis for the allocation of these costs on Worksheet B are required to be made in accordance with CMS Pub. 15-1, 7 P age

36 chapter Numerous requests have been made to the MACs for a change in allocation statistics and order of allocation. Typical requests made include: Changing the statistic for Capital Related Movable Equipment from Dollar Value to Square Feet, Changing the statistic for Pharmacy from charges to patient days, Changing the statistic for Staff Transportation from miles traveled to patient days, Changing the statistic for Nursing Administration from nursing hours to patient days, Changing the order of allocation allowing Plant Operation & Maintenance to be allocated prior to Administrative-General, Changing the order of allocation allowing Housekeeping to be allocated prior to Administrative- General, or Changing the order of allocation allowing Volunteer Services Coordination to be allocated prior to Administrative-General. These requests have been approved by certain MACs while denied by other MACs. Although we cannot speak to the merits of any specific request made, we are concerned about two factors relating to these requests: The same requests were approved by certain MACs while denied by others (consistency in the assessment of the request) and That requests be reviewed with the perspective that hospices may not be able, due to size and other constraints, to comply with the cost reporting instructions as published and an alternative statistic or order of allocation may produce a more accurate cost report. The primary factor regarding approving such requests should be improved cost finding, which would include using information available rather than requiring information that is not available or not obtainable. It is important to recognize that the information required to complete the cost report, based on requirements and instructions, is substantially more extensive than the information required for the previous cost report. Many hospices, especially smaller hospices, do not have the economic or human resources to capture all of the required information. Any communication from CMS to both the industry and the MACs that enhances an understanding of the nature of these requests that could be approved, but with consistent application by the MACs, is greatly appreciated. ENHANCING THE ACCURACY OF COSTS FOR INPATIENT FACILITIES Many hospices operate freestanding hospice facilities and it is expected that the number of dedicated hospice inpatient facilities will increase in the future. The capital related and plant operation expenses associated with inpatient facilities typically have a substantially different (higher) cost per-square foot than the administrative facilities from which hospice services are originated and managed. Currently, the cost report requires that capital-related building costs, capital-related equipment costs, plant operation and maintenance costs, and housekeeping costs be reported in the aggregate for the hospice on lines 1, 2, 5, and 7, respectively, on Worksheet A. This process combines these costs for any freestanding 8 P age

37 inpatient unit and other facilities. The combined costs are then allocated on the basis of square feet, and possibly dollar value, on Worksheet B for the combined costs of all facilities. The cost/patient day by level of care ( LOC ) could be substantially improved if the hospice had the ability to segregate these costs incurred by freestanding inpatient facilities from these costs incurred for other facilities. This could easily be accomplished by opening line 17 (Patient/Residential Care Services) on Worksheet A to capture any capital related, plant operation and maintenance, and housekeeping expenses associated with a freestanding inpatient unit. Inasmuch as Line 17 is ultimately allocated based on in-facility days, these overhead expenses would be allocated only to patients residing in the inpatient unit. If such costs were directly reported on line 17, square feet used to allocate non-freestanding unit costs would exclude the square feet of the inpatient unit as the costs associated with the freestanding unit were directly costed on Worksheet A. There are other ways in which cost finding could be enhanced including adding an additional General Service Cost Center (Inpatient Facility Capital-Related), which would be allocated immediately after the existing capital-related cost centers; however, other options are far more extensive and complicated. PS&R UPDATE Effective January 1, 2016, CMS initiated three (3) separate payments for routine home care days as follows: Routine home care rate (days 1-60 of routine home care provided) Routine home care rate (days 61 and over of routine home care provided) SIA payments (service intensity add-on payments during the last seven days of life, subject to certain restrictions) Based on the Final Rule implementing the three (3) separate rates, CMS provided the following: Hospices will not be required to change how they bill for RHC days to comply with the proposed higher RHC rate for the first 60 days of care and a lower rate thereafter. CMS' claims processing system will be responsible for the count of days, rather than the individual hospices, and will pay the appropriate rate accordingly. We believe this should alleviate hospice providers' concerns about having access to timely information on the patients' day count. There may be cases where a hospice submits a claim for a new admission and expects payment days under the high RHC rate because they are unaware of a prior admission in a sequence of elections. If the prior hospice's benefit period is posted in the Common Working File (CWF) at the time the second hospice's claim is processed, Medicare systems will pay the low RHC rate on that claim and no recoupment will result. While billing vendors have been working on appropriately identifying amounts to be collected under each respective rate, numerous adjustments have been and continue to be made by the MACs as claims are processed. We are hopeful that CMS will give consideration to separately identifying days (hours in the case of SIA payments) and payments for each of the three (3) categories of payments for routine home care on the PS&R for use by the respective hospice. This information could be very useful to hospices in numerous ways, including the reconciliation of payments received to those anticipated by the hospice. 9 P age

38 Finally, we respectfully request that CBSA codes be included on the hospice PS&R report, as is the case on the home health PS&R. REPORTING VACCINE COSTS The Centers for Medicare & Medicaid Services (CMS) issued Change Request 9052/Transmittal 3540, which, effective October 1, 2016, allows hospices to bill Medicare for covered preventive vaccines (influenza virus, pneumococcal, and hepatitis B) directly on the institutional claim rather than requiring that they secure and maintain separate enrollment and bill vaccines as a Medicare Part B Supplier in order to receive payment. Inasmuch as the costs of providing vaccinations are not related to the hospice benefit, we recommend that hospices be advised -- preferably through instructions to the cost report -- that these costs are not to be included in patient care service costs and should be considered non-allowable costs. MAC REVIEW OF SUBMITTED COST REPORTS Regardless of the amount of education offered to hospices and individuals responsible for cost report preparation, we are aware of significantly deficient cost reports being submitted and being accepted by the MACs. The enhancement of Level I errors previously discussed would be very helpful in the determination of acceptable cost report submissions; however, it is obvious that the review by the MAC for basic elements of the cost report submissions would represent a significant opportunity to: 1. Reduce the number of unacceptable cost report submissions and 2. Put cost report preparers on notice regarding the quality of the cost report submission. We recommend CMS consider the following minimum elements for an acceptable cost report submission in addition to those currently conducted and that such be communicated to the MACs: 1. Attachments addressing all Level II edits are provided with the cost report submission, 2. The cost report has been prepared on the accrual-basis of accounting, as required, 3. Expenses reported agree to financial statements, and 4. No expenses that should be reported on Worksheet A are separately reported on Worksheet F-2 and therefore excluded from the determination of LOC costs. We also strongly recommend that the MACs issue a Notice of Amount of Provider Reimbursement (NPR) to hospice providers as a means of final settlement for a cost reporting period. This will facilitate any appeals process if necessary. Currently all home health agency cost reports are settled and an NPR is issued. Of course, we encourage whatever efforts, in addition to those above, can be taken to better ensure the integrity of the cost report submission. 10 P age

39 CONCLUSION As mentioned above, our intent in bringing these concerns and recommendations to you is to ensure that hospice cost reports provide the most accurate data possible to CMS for its deliberations on hospice payment issues, which we believe will be best achieved through requirements that are understandable and that comport with actual hospice practice. We have also included recommendations to incorporate practices utilized with other provider types that we believe will improve the hospice cost reporting and settlement processes. Given the complexity of the issues addressed in this letter, we believe that it would be most productive for representatives of our group (referenced on page 2 of this letter) to meet with you and appropriate staff from the Division of Cost Reporting at your offices in Baltimore. We believe an in-person meeting would provide the best opportunity to present our recommendations and to address any questions that you may have. Once you and your staff have had the opportunity to review these comments, we look forward to hearing from you. Please contact Theresa Forster at or tmf@nahc.org if you have any questions or to arrange for a meeting. Many thanks for your consideration of these comments and of our request to meet to discuss them. Sincerely, William A. Dombi VP for Law Theresa M. Forster VP for Hospice Policy & Programs CC: Yaakov Feinstein Gail Duncan Angela DiGiorgio Amelia Citerone Darryl E. Simms 11 P age