Medicare Regulations and Rules Update What Should You Know?

Transcription

1 Medicare Regulations and Rules Update What Should You Know? Presenters: Gary Massey, CPA & Emily Wetsel, CPA Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC, an SEC-registered investment advisor.

2 Course Objectives Discuss the Overpayment Rule and Lookback Period and how it affects Hospice & Palliative Care Discuss False Claims Act and Other Relevant Regulations and Rules Other Revenue related topics Q&A 2

3 Final Rule: Overpayments, Lookback Period and False Claims Act How do these final rules affect Hospice and Palliative Care agencies? 3

4 Reporting and Returning of Overpayments: FINAL RULE Part of ACA Effective March 14, 2016 Final Rule provides needed clarity and consistency in reporting and returning the self-identified overpayments Why the Overpayment Rule? Promotes the furnishing of high quality care Protect Medicare Trust Funds against fraud and improper payments 4

5 Reporting and Returning of Overpayments: FINAL RULE Self-Identified overpayments (OP) must be reported and returned by the LATER of: The date which is 60 days after the discovery of OP The date any corresponding cost report is due Overpayment Definition 5

6 Reporting and Returning of Overpayments: FINAL RULE Methods of Returning Overpayments Claims Adjustment Credit Balance Self-Reported Refund Other appropriate process to satisfy overpayment Provider must notify appropriate party in writing of identified overpayment State, Intermediary, CMS Contractor, etc. 6

7 Reporting and Returning of Overpayments: FINAL RULE The Overpayment Rule is not unique to Hospices, its universal to all HealthCare and you must comply like any other provider in order to participate in the Medicare program 7

8 Consequences Providers failing to self-report and/or return overpayments could face potential False Claims Act (FCA) liability Civil Monetary Penalties Law liability Exclusion from federal health care programs 8

9 False Claims Act (FCA Liability) Civil Liability for knowingly presenting a false or fraudulent claim No specific intent to defraud the government is required Examples include upcoding, billing for unnecessary services, billing for services/items not rendered, and billing for services provided by an excluded individual FCA protects all whistleblowers who alert the government of suspicious activity (financial incentive to whistleblow) 9

10 False Claims Act (FCA Liability) continued With the increase in the number of law suits regarding FCA liability, some law offices now specialize in this type of litigation against providers Provider could be liable for three times the dollar amount the government is defrauded and civil penalties ($5-10K) for each false claim. $5.86 Million Dollar to resolve Hospice Fraud Allegations in Jackson, MS (St. Joseph Hospice Entities) 10

11 False Claims Act (FCA Liability) continued The Challenge to providers is to create a Culture of Honesty and High Ethics! Setting the tone at the top Creating a positive work enviornment Hiring and promoting appropriate employees Providing sufficient training Confirming accountability for code of conduct Implementing effective discipline 11

12 Lookback Period How does this fit in?? Lookback period reduced to 6 years (previously 10 years) Lookback period will be measured back from the date the person identifies the overpayment Hopes to lessen burden on providers with a shorter lookback period 12

13 Hospice CAP Hospice CAP is a safety valve for Medicare to avoid overpayment Hospice CAP Implications in regard to FINAL RULE? Self-Determined CAP Calculation Moving Forward Agencies responsible for filing CAP calculation with FI 2016 CAP amount is $27, Period 11/1/15 to 10/31/ CAP amount is $28, Period 10/1/16 to 9/30/17 If overpayment calculated, payment is due with the calculation One page calculation, intuitive 13

14 Other Hospice Regulations and Changes 14

15 Hospice Charges The Major payer for most hospice care is Medicare How do you get payments? Look at a sample PS&R How do you set charges? Look at an example 15

16 Hospice Reimbursement Four levels of care NC rural rates Routine Home Care: Services provided in patient s home including a private home, assisted living facility, nursing home. 90%+ of hospice services tend to be Routine Effective 1/1/16, Medicare adopted a two-tiered payment system for routine home care: For the first 60 days of patient s care, Medicare pays hospices $164.36/day; over 60 days of care paid $129.23/day. For hospice nursing and SW services provided in the last 7 days of life, Medicare pays an additional $34.67/hour up to 4 hours/day. Continuous Home Care Supports the patient and caregivers at home through brief periods of crisis to manage acute medical symptoms $34.67/hour up to $832.07/day 16

17 Hospice Reimbursement (continued) Four levels of care (continued) Respite Care Provides up to 5 days relief to the caregiver $152.46/day General Inpatient Care Provides for short-term pain control or acute symptom management in a hospital, inpatient hospice unit or SNF. $640.85/day 2017 Hospice CAP limit $28, Note: All rates above are the FY17 Medicare rates for rural North Carolina hospice providers Reminder that Medicaid is behind in changing over their software to make the two-tier payments 17

18 Hospice Changes Medicare Final rule - rate increase of 2.1% for FY17 (inflation update of 2.7%, reduced by 0.3% productivity adjustment and 0.3% ACA adjustment); but 2% sequestration continues. President s budget proposes a 1.7% rate reduction in each of 2018, 2019, and MedPAC recommends no rate update for hospice. ACA calls for a rebasing of Hospice rates which could have a negative impact on future payments for Hospice services 18

19 Hospice Changes (continued) Regulatory Oversight Increasing scrutiny of hospice due to substantial increase in overall spending OIG focused on hospice provided in nursing homes and assisted living facilities; extensive length of stays; and GIP level of care Intermediaries are reviewing and denying more claims Quality Reporting Additional quality data required from hospices Hospice Compare with star ratings likely by next year 19

20 Hospice Changes (continued) Medicare Advantage/Managed Care Currently Advantage plans allow patients to dis-enroll from their plans and return to traditional Medicare hospice. MedPAC and U.S. Senate support bills to require Medicare Advantage plans to keep patients in their plans who request hospice. Industry is concerned over Advantage plans ability or expectation of managing the full Medicare hospice benefit. 20

21 Questions?

22 Contact Information: Gary Massey, CPA Principal Emily Wetsel, CPA Manager CLAconnect.com linkedin.com/company/ cliftonlarsonallen facebook.com/ cliftonlarsonallen twitter.com/claconnect