2014 HOSPICE REGULATORY UPDATE

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Carmella Harrell
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1 2014 HOSPICE REGULATORY UPDATE Holly Swiger, PhD, MPH, PHN, RN Stellar Concepts, Inc. WHISTLEBLOWERS MARCH 13, 2014 Hospice company to pay $3.92 million to settle false claims allegations; two whistleblowers to share $712,000 2 CMS SENIOR MEDICARE PATROLS Over 5,600 highly trained volunteers who teach others about healthcare fraud Since 1997, taught more than 3.5 million beneficiaries Received more than 300,000 complaints for investigation June 2012 Performance Report Office of Inspector General Recorded more than $106 million in savings 3 1

WASTE, FRAUD & ABUSE Mistakes Inefficiencies Bending the rules Intentional deception Error Waste Abuse Fraud Incorrect

2 FRAUD RECOVERY FEDERAL & STATE BUDGET PRESSURES Cost of the Medicare program continues to grow Medicare growth escalates even more with Baby Boomers Federal Government bears the burden of Medicaid Expansion 5 UNDERSTANDING ERRORS, WASTE, FRAUD & ABUSE Mistakes Inefficiencies Bending the rules Intentional deception Error Waste Abuse Fraud Incorrect coding Medically unnecessary service Improper billing practices (e.g., upcoding) Billing for services that were not provided 6 2

3 HEALTH CARE FRAUD INVESTIGATIONS Forum Tools Players Criminal Civil Administrative GJ subpoenas, search warrants, subpoenas, surveillance (wiretaps) Subpoenas, CIDs, document requests, medical record review Administrative subpoenas, audit requests, contractor audits, OIG audits DOJ, FBI, OIG, MFCU, AG DOJ, Relators, OIG, MFCU, AG MACs, OIG, ZPICs, RACs Parallel investigations all of the above! 7 COMPARE YOUR HOSPICE PROGRAM S DATA TO NHPCO S Non-CA Diagnosis 63.1% Patients with LOS> 6 months 11.5% ALOS > Median LOS 18.7 Number of live discharges (revocations & discharges) 21% Number of readmissions 5% Patients residing in LTC facilities 18.3% Patients residing in Assisted Living facilities 6.6% Days of GIP 2.7% Days of continuous care - 0.5% MEDICARE CONTRACTORS CA & NV Medicare Administrative Contractor (MAC) Palmetto GBA Recovery Auditor (RA) Connolly Zone Program Integrity Contractor (ZPIC) Health Integrity 9 3

4 MEDICARE CONTRACTORS CA & NV, CONT D State Medicaid Auditors- DADS Medicaid Integrity Contractor (MIC) Audit MIC Health Management Systems (HMS) 10 UNIFIED PROGRAM INTEGRITY CONTRACTOR (UPIC) ZPIC & MAC to merge Focus will be on both Medicare & Medicaid integrity issues MAC would take on a broader role in program integrity activities Medicaid Integrity Contractors will be phased out Recovery Auditors will remain in place Medicare & Medicaid data will be a unified database 11 OIG S FOCUS ON HOSPICE Coverage requirements for hospice patients residing in nursing homes Medicare hospices that focus on nursing facility residents ( high percentage hospices ) Hospital-to-GIP transfers Marketing practices with nursing facilities Duplicate drug claims (including non-covered but hospice-related medications) Compliance with Medicaid reimbursement requirements GIP appropriateness 12 4

5 GIP CRACKDOWN The Federal government recently reached a $2.7 million settlement with a hospice for allegedly billing Medicare for GIP when beneficiaries actually received routine home care, which has a lower reimbursement rate OIG WORK PLAN - HOSPICE Hospice Provision of GIP Review claims and patient records Evaluate for eligibility for this higher level of care Hospice in Assisted Living Facilities (ALF) Have the longest LOS in hospice. Review the numbers of hospice beneficiaries in ALFs, their LOS & common diagnoses Utilize this information for payment reform Develop quality measures Expected issue date for both evaluations in FY OIG RECOMMENDATIONS Establish a hospital transfer payment policy for early hospital discharges to hospice care Monitor Hospices that depend heavily on SNF residents & modify the payment system for hospice care in SNFs Seek legislation or promulgate regulation to set specific timeframes for the frequency of hospice surveys 15 5

6 CURRENT OIG OUTCOMES FOR HOSPICE Currently 6 hospices with Corporate Integrity Agreements June 2013 January hospice professionals convicted of fraud 3 hospices settled for fraud allegations Several hospices have closed due to the burden of the scrutiny 16 ZPIC AUDIT FOCUS IN HOSPICE é Length of Stay (LOS) é Non-CA diagnosis é SNF care é Readmits after discharge é Higher levels of care GIP & Continuous Care Technical and clinical compliance Medical necessity 17 ZPIC/MIC AUDITS They act as if one didn t know the other was coming Record volume submission can be a tremendous burden Medicare and Medicaid separate requests with immediate deadlines It took 16 people working FT One request was for 200 records Can take 1 2 years to hear results Sample review can lead to 100% pre-payment review prior to audit results Extrapolation can be deadly Frequently the statistical sampling and extrapolation is incorrect 18 6

7 RANGE OF HOSPICE ZPIC CLAIMS $0.00 to $112.8 million in hospice repayments Same ZPIC Contractor Difference was in the eligibility documentation and medical necessity 19 RECOVERY AUDITORS ON HOLD Current RA activity on hold Last date for a post-payment audit was 2/21/14 Current contracts only in place until 12/31/15 for administrative & transition activities New contracts are to be awarded at some time in the future Purpose is to allow current contractors to handle current appeals 65 ALJs have a backlog of 460,000 appeals able to handle 2,000/wk. Once backlog is caught up, RACs can go back and review claims in this paused period CMS PLANNED CHANGES TO THE RECOVERY AUDIT PROGRAM RACs must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment. RACs must confirm receipt of a discussion request within 3 days RACs must wait until the 2 nd level of appeal is exhausted before they receive their contingency fee CMS is establishing revised ADR limits that will be diversified across different claim types CMS will require RACs to adjust limits in accordance with a provider s denial rate. Providers with low denial rates will have lower ADR limits. 21 7

inappropriate RAC denials have created in their appeal process creating increased financial strain 22 POLICY MAKER QUESTIONS Are patients being admitted too soon?

8 RAC PAUSE IMPACT Any relief in audit contractor activity feels good! RACs have not been as big a burden for the hospice industry as for other healthcare sectors If hospices have had RAC audits, it won t address the multi-year backlog that inappropriate RAC denials have created in their appeal process creating increased financial strain 22 POLICY MAKER QUESTIONS Are patients being admitted too soon? Data shows that there are more patients with much longer lengths of stay > 180 days What about short stays? What are the reasons for short stays? Why would some hospices have large numbers of live discharges? Does this indicate other problems with quality or management? 23 MAJOR RISK AREAS Technical Risks Clinical Risks 24 8

MAJOR TECHNICAL RISKS Election Statement Certification & Recertification Plan of Care 25 TECHNICAL RISKS Easy targets to identify and recoup money Missing elements on an election form voids the

9 MAJOR TECHNICAL RISKS Election Statement Certification & Recertification Plan of Care 25 TECHNICAL RISKS Easy targets to identify and recoup money Missing elements on an election form voids the election Missing or incorrect dates Simple errors can invalidate the certification or recertification No ability to appeal denials Plan of Care not followed, not updated, not provided, etc. #2 Palmetto denial is No plan of care submitted 26 MAJOR CLINICAL RISKS Eligibility for Hospice & General Inpatient/Continuous Care Discharges & Revocations Related vs. Not Related to the terminal illness 27 9

10 PHYSICIANS ROLE IN ELIGIBILITY #1 reason for Palmetto denials is patient not appropriate Physician narrative can make or break reimbursement Detailed description of clinical findings to support the limited prognosis Keep unrelated diagnoses and medications out of the narrative Growing reason for denial is due to the Face-to-face requirements not being met Palmetto #3 28 PHYSICIANS ROLE IN ELIGIBILITY MHB requires hospice to cover all palliative care related to the terminal illness and related conditions Physicians must help the IDG in identifying related, secondary, contributing and unrelated diagnoses All services are considered related unless the hospice physician documents why a patient s medical needs are unrelated to the terminal illness Appropriate ICD-10 coding will only occur with sufficient information from your Attending Physician 29 ALLEGED LACK OF MEDICAL NECESSITY Hospice company XYZ, Inc., agreed to pay $25 million to resolve allegations that it submitted false claims to federal programs for medically unnecessary continuous home care services billed at a higher rate than routine care services. As a result, XYZ, Inc., entered into a Corporate Integrity Agreement (CIA) with HHS/OIG 30 10

11 MEDICAL NECESSITY IN HOSPICE IDT documentation is essential in demonstrating medical necessity Meet LCDs at admission and ongoing Documentation demonstrates decline over time Intake, Mid arm circumference, weights Dependency in ADLs Burden of illness on caregivers Changes in the POC demonstrate need Higher level of care Medication & treatment changes Increase in visit frequency & type of hospice support Each claim s documentation must stand on its own merit 31 COMMENTS FROM A ZPIC AUDIT There was no indication in the submitted documentation that the beneficiary s life expectancy was 6 months or less. There was no documentation of co-morbidities that would have contributed to a short life expectancy. The documentation shows that the patient required full time custodial care, but not the services of Hospice. 32 DEBILITY & ADULT FAILURE TO THRIVE CMS clarified that debility and adult failure to thrive SHOULD NOT be used as principal hospice diagnoses on the hospice claim form Claims will be returned to the provider (RTP) beginning Oct. 1, 2014 for a more definitive principal diagnosis Debility and adult failure to thrive could be listed on the hospice claim as secondary or related comorbid diagnoses CMS expects providers to code the most definitive, contributory terminal diagnosis in the principal diagnosis field with all other related conditions in the additional diagnoses fields 33 11

12 STEPS IN CHANGING THE PRIMARY DIAGNOSIS Obtain a physician order for the new diagnosis Obtain a new physician note that supports eligibility for the new diagnosis Ensure that the new diagnosis is supported by documentation in the clinical record Develop a new POC based on an updated comprehensive assessment Update the drug profile with appropriate designations of related/covered or unrelated/non-covered 34 STEPS IN CHANGING THE PRIMARY DIAGNOSIS (CONT D) Change billing codes The diagnosis can be changed on the next claim, or an adjustment may be made to a prior claim if needed If the patient has no clear alternate diagnosis that can be supported by clinical documentation, and the POC has not changed over time to reflect end-of-life symptom management, consideration should be given to discharge the patient 35 DIAGNOSES ON CLAIM FORMS Report the primary diagnosis, all secondary diagnoses, and all co-existing diagnoses used to justify a 6-month prognosis Unrelated diagnoses should be part of your clinical record but Not placed on the claim form 36 12

13 OIG REPORT A JUNE 2012 During CY09 Medicare Part D paid over $33 Million for drugs of hospice patients 14.9% of hospice patients enrolled in Part D had $12.9 million in analgesics paid by Part D 10% of hospices accounted for 51% of Part D analgesic claims 50.3% of these claims were for SNF-based hospice patients PART D FINAL GUIDANCE 3/11/14 We expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances CMS No drug recoupments until 5/1/14 Part D plans are instructed to establish a prior authorization process on ALL drugs of Medicare Hospice Benefit patients Hospices have the option to prospectively initiate prior authorizations PART D FINAL GUIDANCE 3/11/14 Pharmacies will either bill the hospice for unauthorized drugs or let the hospice use its usual pharmacy source The independent reviewer component is on hold until future guidance When Part D has paid for a drug that is determined to be a hospice liability, the hospice and Part D plan sponsor will solve the payment issue If hospice provides a drug that the patient wants, but is not part of the POC, and ABN must be issued 13

14 PART D OPERATIONAL CHANGES Proactively identify Part D sponsor and initiate prior authorization as soon as patient elects Adjust admission process to: Collect patient s Part D information Describe the possibility that the patient may be liable for some drugs Contact any prescribers to initiate care coordination Adjust medication management process Have physician determine unrelated medications Have physician document reasons for un-relatedness for submission in prior authorization 40 DRUG PAYMENT RESPONSIBILITY Hospice Drugs related to the palliation and management of the patient s terminal illness or related conditions Medicare Part D Drugs for the treatment of a condition that is completely unrelated to the patient s terminal illness or related conditions Beneficiary 1)Related drugs not reasonable or necessary to palliation or symptom management; or 2)Patient wants a specific drug instead of its equivalent on the hospice s formulary 41 SITES FOR INFORMATION NOMNC Notice of Medicare Non Coverage ABN Advance Beneficiary Notice of Non-coverage DENC Detailed Explanation of Non Coverage CMS Beneficiary Notice Website Information/BNI 42 14

15 ABN/NOMNC/DENC RESOURCES ICN April Learning-Network-MLN/MLNProducts/downloads/ abn_booklet_icn pdf CMS, Change Request 7903, Expedited Determinations for Provider Service Terminations. May 24, Transmittals/Downloads/R2711CP.pdf CMS, Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, page Manuals/downloads/clm104c30.pdf 43 ADDITIONAL DATA COLLECTION ON CLAIM FORM CR 8358 reissued with clarifications Jan 31, 2014 Mandatory implementation was April 1, 2014 MACs have issued their Q & A documents 44 ADDITIONAL DATA COLLECTION ON CLAIM FORM Hospice staff visits under GIP in contract facilities Facility NPI must be reported when the place of service is a non-skilled NF, SNF, hospital, hospice facility (if different from the billing hospice), long term care facility or inpatient psychiatric facility regardless of the Level of care Post-mortem visits by hospice staff on the date of death to reported with HCPCS modifier PM Injectable drugs per fill with revenue code 0636 and the appropriate HCPCS code, for all patients & levels of care Non-injectable drugs with revenue code 0250 and the National Drug Code (NDC) Infusion pumps per pump order with 029X and medication fill/refills with 0294 and appropriate HCPCS 45 15

16 CONCERNS WITH CR line limit on claim form NDC qualifier availability EMR software vendors and pharmacy vendor electronic communication Billing complexities and delays Need for charges & NDCs for dispensed meds in contracted GIP 46 HELPFUL RESOURCES Palmetto GBA Q & A on CR 8358 Healthcare Common Procedure Recording System (HCPCS) codes then go to the Medicare tab > HCPCS Release & Code Sets > Alpha-Numeric HCPCS Items > Details for Year 47 HOSPICE QUALITY REPORTING PROGRAM Hospices should have reported data for the QAPI Structural Measure and NQF 0209/Pain measure for all of 2013 by April 1, 2014 If your data was not submitted, 2% market basket financial penalty FY 2015 The CMS QAPI structural measure and NQF #0209/Pain measure have been discontinued CoP QAPI requirements remain the same and you certainly can continue to include those measures for your agency 48 16

17 HOSPICE ITEM SET (HIS) A standardized mechanism for abstracting data from the medical record It is not a patient assessment instrument and it will not be administered to the patient and/or family or caregivers 49 HOSPICE ITEM SET (HIS) Proposed to begin the use and submission of HIS on July 1, 2014 Electronic data submission on admission and discharge of every patient on or after 7/1/ new quality measures with a rolling data submission Hospices who fail to report quality data via the HIS system in 2014 will have a 2% market basket reduction for FY2016 (10/1/2015) 50 HOSPICE ITEM SET MEASURES NQF #1617 Patients Treated with an Opioid who are given a bowel regimen NQF #1634 Pain Screening NQF #1637 Pain Assessment NQF #1638 Dyspnea Treatment NQF #1639 Dyspnea Screening NQF #1641 Treatment Preferences NQF #1647 Beliefs/Values Addressed (if desired by the patient) (modified) 51 17

18 QUALITY REPORTING Form Completion & Data Submission Electronically online Ongoing submission 14 days from admission to complete HIS Admission 7 days from discharge to complete HIS Discharge 30 days from a patient admission or discharge to submit 52 MEASURES Specifications of measures are found at: National Quality Forum (NQF) Final Report on Palliative and End of Life Measures Palliative_Care_and_End-of-Life_Care.aspx#t=1&s=&p= 53 CMS RESOURCES CMS HQRP web site HIS page HIS Manual HIS Training Slides Quality Help Desk HospiceQualityQuestions@cms.hhs.gov 54 18

19 HOSPICE EXPERIENCE OF CARE SURVEY (HECS) Post-death family caregiver survey: CY2015 Part of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys If you are exempt if your hospice had fewer than 50 deaths in CY 2014 Borrows heavily from FEHC Focuses on the patient/caregiver experience of care, rather than patient satisfaction 55 HOSPICE EXPERIENCE OF CARE SURVEY (HECS) Core set of questions Additional setting specific questions with 3 versions determined by location of death: Home Nursing Home Inpatient care Hospices must contract with a vendor for survey administration and quarterly data submission 56 HOSPICE EXPERIENCE OF CARE SURVEY (HECS) Implementation Mandatory dry run for at least 1 month in the first quarter of CY 2015 Continuous participation starts April 1, 2015 Lack of participation will affect FY 2017 payment (10/1/16) Dedicated survey website Google: CMS

20 ICD-10 ICD 10 implementation was delayed & will replace ICD 9 no sooner than October 1, 2015 ICD-10 coding is very different from ICD-9 It will impact admissions, EMRs, billing & related/ unrelated determinations ICD-10 coding in other countries slowed process by 40% Hospices must begin the training & evaluation of the impact on hospice systems & operations Have staff ready to cross code (both in ICD-9 & ICD-10) early in 2015, at the vary latest. 58 ICD-10 Even veteran coders will need to start from scratch Coders need to brush up on anatomy & physiology as diagnosis coding will require more specificity of site of disease processes, including site and side of body for wound and fracture codes and cancers It may be time to consider an external contracted coding company to assist in coding and billing ICD10/index.html 59 EMERGENCY PREPAREDNESS Proposed rule posted 12/27/13 Will become a new CoP under Subpart D, Administration Proposed regulations encourage coordination of preparedness efforts within provider communities and states as well as across state lines Comment submission closed 3/31/

21 EMERGENCY PREPAREDNESS Four core elements Risk Assessment and Planning Policies and Procedures Emergency Preparedness Communication Plan Training and Testing Requirements for both home hospice and inpatient hospice providers 61 HOSPICE PAYMENT REFORM Current models being studied by Abt Associates: MedPAC recommended U-shaped model Tiered model payments based on length of stay Short stay add-on, similar to Home Health Low Utilization Payment Amount (LUPA) Case-mix model Rebasing the Routine HC rate Site of service adjustment for hospice patients in nursing facilities 62 PAY-FOR-PERFORMANCE HHS Secretary is required to establish a pilot program to test value-based purchasing under hospice. Pilot testing for Pay-for-performance to occur no later than January 1,

22 MEDPAC RECOMMENDS CARVE-IN In its March 2014 report to Congress, MedPAC recommended that Medicare Advantage plans assume both the clinical management and financial responsibility of the hospice benefit Anew study commissioned by NHPCO projects that the carve-in would create an additional cost to Medicare of $1.3 Billion over a 10-year budget window It would remove choice for the beneficiary Hospices would not be assured the baseline reimbursement rates Administrative coordination, billing and data reporting would increase for hospice 64 MEDPAC Recommends reimbursement freeze for hospice providers for MEDICARE CARE CHOICES MODEL Allows the hospice to provide specific palliative care services and care coordination while the patient is still receiving curative services All visit services under routine care Inpatient respite Care coordination with curative services Shared decision making with patients & families Hospice paid $400/per member/per month No financial support to administer this 3 year demonstration DME, OT, ST, PT, and Rx are billed to the appropriate part of Medicare (A, B, or D) by the provider 66 22

23 MEDICARE CARE CHOICES MODEL Hospice must be: Certified & in good standing without exceeding cap in Experience in care coordination Apply before June 19, 2014 Implement within 180 days of acceptance 67 MEDICARE CARE CHOICES MODEL Patient Eligibility Eligible for the Medicare Hospice Benefit (MHB) Not have elected MHB in last 30 days Enrolled in Medicare A, B, & D Not enrolled in a Medicare managed care plan in the past 2 years Have a diagnosis of CA, COPD, CHF or HIV Had at least 2 hospitalizations in past 12 months Have had at least 3 office visits with their Medicare physician in past 12 months Lives in a traditional home (NOT an institutional setting) Agrees to actively participate in the patient-centered goals planning process 68 PEPPER REPORT TMF Health Quality Institute is developing a secure web portal through which certain providers can access their Program for Evaluating Payment Patterns Electronic Report (PEPPER) Should be able to download in April/May 2014 They will remain accessible for 1 year To receive notification when the PEPPER is available & guidance on accessing it, join the list at PEPPERresources.org 69 23

24 COST REPORT New forms and instructions not yet final Projected start date for cost report periods beginning October 1, VOLUNTARY DISCLOSURE REQUIREMENTS Only audit pre-billed clinical records You can adjust billing prior to submission if documentation is missing or does not support billing If problems are identified, they must be voluntarily reported and refunded within 60 days of identifying an overpayment ACA Section 6402 final regs in 2014 If significant refund potential or inducements involve counsel SURVEY STATS FOR CY ,970 active hospice providers 1,301 number of surveys of hospice providers L Tag # L0543 L0545 L0530 L0555 L0547 L0591 L0629 L0557 L0533 L0671 Tag Description Plan of Care Content of Plan of Care Content of Comprehensive Assessment Coordination of Services Content of Plan of Care Nursing Services Supervision of Aides Coordination of Services Updates of Comprehensive Assessment Clinical Records 72 24

25 COMPLIANCE CALENDAR Regulation Date Hospice Payment Reform No earlier than FY 2014 Mandatory quality reporting of 2013 indicators April 1, 2014 Mandatory additional data reporting April 1, 2014 Part D Non-related Rx justification May 1, 2014 Medicare Care Choices Model application due June 19, 2014 Hospice Item Set (HIS) implementation July 1, 2014 All Business Associate agreements meet HIPAA Omnibus Rule September, 22, 2014 Claim denials for Debility & AFTT October 1, COMPLIANCE CALENDAR - Continued Regulation Date New cost report forms and instructions For cost report periods beginning Oct Voluntary disclosure regulations 2014 Emergency Preparedness COP /15 Hospice Experience of Care Survey dry run 1 st Quarter, 2015 Hospice Experience of Care Survey (HECS) April 1, 2015 ICD-10 Implementation Not prior to FY 2015 Pilot testing for Pay-for-Performance No later than 1/1/16 Public Reporting of Hospice Quality Measures Not prior to PRESENTER Holly Swiger, PhD, MPH, PHN, RN Stellar Concepts, Inc. hswiger@me.com 75 25

THE HOSPICE REGULATORY MERRY-GO-ROUND

THE HOSPICE REGULATORY MERRY-GO-ROUND HAVE YOU HAD YOUR ANTIVERT TODAY? 2 OBJECTIVES Name a current & proposed change in reimbursement for hospice. Define the impact of not using Debility & Adult Failure