Automating documentation helps hospice agencies withstand greater scrutiny

Transcription

1 White Paper Automating documentation helps hospice agencies withstand greater scrutiny Documenting care plan, procedures key to staying in regulatory compliance Abstract The importance of strong documentation to the continued success of hospice agencies cannot be ignored. Higher usage of hospice services, longer length of stays and corresponding variability in Medicare and Medicaid reimbursements have brought heightened awareness of the need for accurate documentation to reduce duplicative services and instances of potential fraud and abuse. Hospice services have long been scrutinized by federal agencies such as Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG), an arm of the U.S. Department for Health and Human Services. But that scrutiny has increased recently as more Americans seek hospice services. According to CMS, over the past dozen years, the number of Medicare beneficiaries using hospice services has risen more than 150%, from 513,000 in FY2000 to more than 1.3 million in FY2012. During the same period, expenditures have increased 400% to $14.7 billion in FY CMS has begun new initiatives to compel hospice agencies to more specifically describe health declines to more closely tie care to reimbursement. Meanwhile, the OIG is stressing compliance with the risk areas it outlined more than a decade ago, and other Medicare contractors have been charged with stepping up efforts to curb fraud and abuse. This white paper will illustrate the importance of automated recordkeeping systems to help hospice agencies create the documentation that illustrates their compliance with increasingly complex industry regulations. OIG s continued interest in hospice practices While hospice usage and length of stay have increased over the past 10 years, so has scrutiny of the industry fueled a more intense focus on fraud and abuse as facets of the Affordable Care Act are implemented. As Judi Lund Person, vice president of the National Hospice and Palliative Care Organization, noted in the organization s digital magazine NewsLine, The Office of

2 Inspector General (OIG) identified 28 risk areas for hospice in 1999 that are still very relevant today. In fact, hospice eligibility and the documentation to support eligibility remains the top target area for compliance. 2 The 1999 OIG analysis concluded that the Medicare hospice program appeared to be working as it was intended. However, the agency listed more than two dozen potential areas of risk for hospice programs. One-quarter of those were directly or indirectly related to documentation: Falsified medical records or plans of care Untimely and/or forged physician certifications on plans of care Insufficient oversight of patients, in particular, those patients receiving more than six consecutive months of hospice care Deficient coordination of volunteers Improper indication of the location where hospice services were delivered Failure to comply with applicable requirements for verbal orders for hospice services Failure to adhere to hospice licensing requirements and Medicare conditions of participation 3 In 2009, OIG released an analysis of hospice claims submitted in 2006 for beneficiaries in nursing facilities to determine compliance with Medicare coverage requirements. The analysis revealed deficiencies that an automated practice (The OIG) listed more than two dozen potential areas of risk for hospice programs. One-quarter of those were directly or indirectly related to documentation. management solution should help hospice agencies solve: Eighty-two percent of hospice claims for beneficiaries in nursing facilities did not meet at least one Medicare coverage requirement. Eighty-one percent of claims did not meet at least one Medicare coverage requirement pertaining to election statements, plans of care, services or certifications of terminal illness. Claims from not-for-profit hospices were less likely (89%) to meet Medicare coverage requirements than those from for-profit hospices (74%). Thirty-three percent of claims did not meet election requirements. Most commonly, the statements did not explain that hospice care was palliative rather than curative or that the beneficiaries waived Medicare coverage of certain services related to their terminal illnesses. Sixty-three percent of claims did not meet plan-of-care requirements. These plans of care were not established by an interdisciplinary group; they did not include necessary components, such as a detailed description of the scope and frequency of services; or they did not specify intervals for review, as required. Thirty-one percent of claims were for fewer services than outlined in beneficiaries plan of care; the hospices did not provide the number of services outlined in the plans of care that they established. Four percent of claims did not meet certification of terminal illness requirements, and for another 4% of claims, the certifications were missing or did not meet one or more federal requirements. 4 Based on these findings, OIG made several recommendations to CMS, including educating hospices about coverage requirements and their importance and providing tools to help agencies achieve compliance with CMS regulations. The report also urged CMS to effectively use targeted medical reviews and other oversight mechanisms to improve hospice performance and compliance with Medicare requirements, especially with respect to establishing plans of care and providing services that are consistent with these plans of care. Additionally, as we recommended in a previous report, CMS should conduct more frequent certification surveys of hospices as a way to enforce the requirements. 5 2

3 In its fiscal year 2013 work plan, the OIG announced several efforts related to hospice, including examinations of: Payments to acute care hospitals for patient discharges into hospice Marketing practices of hospices and their financial relationships with nursing facilities, focusing on hospices with high percentages of patients in such facilities Care claims related to hospice beneficiaries receiving inpatient care Medicaid payments to states for hospice services and whether those payments comply with federal reimbursement requirements 6 Current regulatory compliance efforts An alphabet soup of federal agencies is charged with monitoring payments for federal programs, including hospice. An automated agency management solution can be key to helping ensure that agency documentation is complete, complies with appropriate regulations and includes an actionable care plan. When announcing a 1% net increase in payments to begin in FY2014, CMS also revealed plans to reject claims that contain nonspecific diagnoses in billing codes, an issue that an agency management software solution can help address. Hospices also face a 2% reduction to their market basket update in FY2014 for failing to report mandated quality data, even though the NQF #0209 Pain Management measure and structural measure on Quality Assurance and Performance Improvement participation will be phased out in FY2016. The Additional Data Reporting Requirements for Hospice Claims (CR8358), effective April 1, 2014, imposes new reporting requirements for hospice agencies. Hospices must report a lineitem list of the prescription medications provided to each patient. For each fill or refill, the pharmacy has to provide a National Drug Code (NDC) qualifier that s put on the claim form. General inpatient (GIP) calls and visits made by paid hospice staff need to be reported on claims with length of visit information (rounded to the nearest 15-minute increment) for nurses, aides, social workers and therapists who are employed by the hospice. For post-mortem visits on the calendar day of death, length of visit information (rounded to the nearest 15-minute increment) must be reported for nurses, aides, social workers and therapists who are employed by the hospice, using a post-mortem (PM) modifier. National Provider Identifier (NPI) of any nursing facility, hospital or hospice inpatient facility where the patient is receiving services, regardless of the level of care provided, should be provided when the site of service is not the billing hospice. 7 Starting July 1, 2014, agencies are required to collect the Hospice Item Set (HIS) at admission and discharge. The HIS includes information on the following seven National Quality Forum-endorsed measures of hospice patient care: 8 1. NQF #1617, Patients treated with an opioid who are given a bowel regimen 2. NQF #1634, Pain screening 3. NQF #1637, Pain assessment 4. NQF #1638, Dyspnea treatment 5. NQF #1639, Dyspnea screening 6. NQF #1641, Treatment preferences 7. Modified NQF #1647, Beliefs/ values addressed (if desired by the patient) In a fact sheet about HIS, CMS explains that an item set is a standardized mechanism for abstracting data from a medical record. In other words, hospices are not capturing this information from patients as a new assessment tool; they should be mapping existing items in their clinical records to items in the HIS. Some providers may need to add HIS items to their clinical records or existing patient assessment forms. Hospices have 14 days from the date of admission to complete the admission tool and seven days from discharge for the discharge tool. All completed records must be submitted to CMS within 30 days. 9 Finally, CMS proposes a Hospice Experience of Care Survey for informal caregivers of hospice patients that s expected to begin in

4 These examples underscore the importance of an automated agency management system to help create and maintain proper documentation that precisely tracks against the care plan, noting changes when a patient s condition warrants. The Health Care Fraud and Abuse (HCFAC) Program has been in existence since 1997, returning more than $23 billion to federal coffers. Enforcement has stepped up since the 2009 creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to prevent fraud, waste and abuse in Medicare and Medicaid. Efforts over the past four years have recovered $14.9 billion. 11 As part of their contract, Medicare Administrative Contractors (MACs) conduct medical reviews of claims. Although the percentage of claims selected for review is small, the number of Additional Documentation Requests (ADRs) has increased recently, according to Lund Person from NHPCO. 12 Medicaid Integrity Contractors target fraud, waste and abuse in the Medicaid program. CMS hires contractors responsible for reviewing and auditing claims, identifying overpayments and educating providers and others on issues of integrity. 13 Recovery Audit Contractors (RACs) audit both Medicare and Medicaid payments, with the ability to look back three years as part of their audit function. 14 Zone Program Integrity Contractors (ZPICs) perform complementary functions to MACs to investigate potential fraud, waste and abuse, preventing what the contractor sees as inappropriate payments and working with MACs to recover payments that have been sent. 15 Audits increase among federal programs Implementing programs to comply with the Affordable Care Act has brought new awareness of the potential for fraud, waste and abuse, drawing additional focus away from payers. HHS has stripped more than 14,000 Medicare providers and suppliers of their ability to bill Medicare over the past two years, a twofold increase over the previous two years. 16 A high-profile audit case involved San Diego Hospice, which declared bankruptcy and closed its doors after a whistleblower claim and federal audit of its billing practices. The federal government filed a $120 million claim against the hospice as its assets were liquidated. 17 The OIG released a report in spring 2013 that questioned whether hospice inpatient stays were being correctly billed and whether patients were receiving the appropriate level of care. Hospices with inpatient units (IPUs) provided more inpatient care and for longer periods of time than hospices without IPUs. One-third of patient stays were longer than five days, with 11% longer than 10 days. The OIG did not make formal recommendations as a result of its analysis, but the agency urged CMS to monitor closely inpatient billing, which accounted for $1.1 billion in spending in These examples underscore the importance of an automated agency management system to help create and maintain proper documentation that precisely tracks against the care plan, noting changes when a patient s condition warrants. Hospices also should conduct regular audits as part of a compliance program to help ensure that Medicare charges have been accurately recorded and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide a hospice s auditing and monitoring activities. National hospice claims data should be analyzed to identify target areas that could be at risk for improper Medicare payment. PEPPER shows a particular hospice s statistics compared to target areas to help an agency uncover payments that might be improper. 19 Conditions of Participation demand strong documentation Hospice agencies fall under the CMS Conditions of Participation (CoPs) covering healthcare entities that provide services to Medicare and Medicaid beneficiaries. Comprehensive documentation 4

5 is a key component of many CoPs that cover hospice, including the following sections and subsections: , Initial and comprehensive assessment of the patient , Interdisciplinary group, care planning and coordination of services , Quality Assessment and Performance Improvement (QAPI) (a) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. (2) The hospice must measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations , Hospices that provide hospice care to residents of a SNF/ NF or ICF/MR (d) Standard: Hospice plan of care. In accordance with , a written hospice plan of care must be established and maintained in consultation with SNF/NF or ICF/MR representatives. All hospice care provided must be in accordance with this hospice plan of care. (1) The hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. (2) The hospice plan of care reflects the participation of the hospice, the SNF/NF or ICF/MR, and the patient and family to the extent possible. (3) Any changes in the hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/MR representatives, and must be approved by the hospice before implementation. Summary An automated agency management system that helps provide strong documentation in a hospice agency should form the backbone of the care experience, with patient conditions, prognosis, medications, care plan and more in a central location that authorized care providers easily can access. A hospice management system should prompt clinicians to complete necessary documentation to create a comprehensive care plan, speed the QA process, and, ultimately, speed reimbursement. But just as important, hospice system automation should help create the strong documentation necessary to withstand the heightened scrutiny hospice agencies face as lengths of stay are extended and reimbursements increasingly are under review. McKesson Corporation s white papers are made available for educational purposes only as well as to give you general information, not to provide legal advice. By reading white papers you understand that there is no attorney-client relationship created between you and McKesson. Although the information in our white papers is intended to be current and accurate, the information presented therein may not reflect the most current legal developments, regulatory actions or court decisions. These materials may be changed, improved, or updated without notice. McKesson is not responsible for any errors or omissions in the content of this site or for damages arising from the use or performance of this site under any circumstances. We encourage you to contact us or other legal counsel for specific legal advice as to your particular matter. 5

6 Endnotes 1 Hospice FY2014 Payment, Wage Index Final Rule Issued: Debility, AFTT Prohibited as Principal Diagnoses Starting October 1, 2014 (PART ONE), accessed April 28, 2014, NAHCReport/nr130805_1/. 2 Judi Lund Person, Fraud and Abuse: What You Need to Know and Do, NewsLine, April 2013, nxtbook.com/nxtbooks/nhpco/newsline_201304/index. php?startid=8. 3 Office of Inspector General s Compliance Program Guidance for Hospices, September 1999, gov/authorities/docs/hospicx.pdf. 4 Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements, accessed April 28, 2014, gov/oei/reports/oei pdf. 5 Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements, September 2009, reports/oei pdf. 6 HHS OIG Work Plan, FY2013, reports-and-publications/archives/workplan/2013/ Work-Plan-2013.pdf. 7 Additional Data Reporting Requirements for Hospice Claims, accessed April 28, 2014, Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8358.pdf. 8 Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform, August 7, 2013, articles/2013/08/07/ /medicare-program-fy hospice-wage-index-and-payment-rate-updatehospice-quality-reporting. 9 Fact Sheet: The Hospice Item Set (HIS), accessed April 28, 2014, Initiatives-Patient-Assessment-Instruments/Hospice- Quality-Reporting/Downloads/HIS-Fact-Sheet.pdf. 10 CMS finalizes updates to the wage index and payment rates for the Medicare hospice benefit, August 2, 2013, Fact-Sheets/2013-Fact-Sheets-Items/ html. 11 Departments of Justice and Health and Human Services announce record-breaking recoveries resulting from joint efforts to combat health care fraud, accessed February 11, 2013, press/2013pres/02/ a.html. 12 Judi Lund Person, Fraud and Abuse,, nxtbook.com/nxtbooks/nhpco/newsline_201304/index. php?startid=8. 13 Medicaid Integrity Program - General Information, accessed April 28, 2014, Medicare-Medicaid-Coordination/Fraud-Prevention/ MedicaidIntegrityProgram/index.html?redirect=/ medicaidintegrityprogram/. 14 Recovery Audit Contractor, accessed April 28, 2014, 15 The Role of the Zone Program Integrity Contractors (ZPICs), Formerly the Program Safeguard Contractors (PSCs), accessed May 23, 2014, MLNMattersArticles/downloads/SE1204.pdf. 16 Kelly Kennedy, Policing of Medicare fraud explodes over two years, June 5, 2013, story/news/politics/2013/06/05/medicare-revokingproviders-billing-fraud/ /. 17 Paul Sisson, Scripps closes escrow on SD Hospice building, accessed July 24, 2013, utsandiego.com/news/2013/jul/24/scripps-san-diegohospice-escrow/. 18 Report: Medicare Hospice: Use of General lnpatient Care, OEI , accessed May 23, 2014, 19 Hospice Program for Evaluating Payment Patterns Electronic Report User s Guide, Second Edition, accessed April 28, 2014, LinkClick.aspx?fileticket=zNgXyfqCcpo%3d&tabid= Electronic Code of Federal Regulations, Part 418 Hospice Care, accessed April 28, 2014, gpoaccess.gov/cgi-bin/text-idx?sid=fcf99fb5f19cdfa2c65 8f5967c150aa6&node=42: &rgn=div5. McKesson Connected Care and Analytics 5995 Windward Parkway Alpharetta, GA Copyright 2014 McKesson Corporation and/or one of its subsidiaries. All rights reserved /14