401. Hospice Compliance Management: Lessons Learned from Pre-Claim Review

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Grace Dawson
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1 Introductory announcements: This provider-directed continuing nursing education activity was approved by the Maryland Nurses Association (MNA) to award contact hours. The MNA is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center (ANCC) Commission on Accreditation and refers only to continuing education activities, and does not imply endorsement of any product, service, or company referred to in this activity. Attendance for the full session is required to receive continuing education credits Please complete an online evaluation for each session you attend CE certificates will be available through within a few days Please silence your phone 401. Hospice Compliance Management: Lessons Learned from Pre-Claim Review Lisa Eick, RN Clinical Consultant Wayne van Halem, President 1

2 Agenda Background on Pre-Claim review for home health Update on home health demonstration project OIG Scrutiny on Hospice Providers Common hospice payment threat and compliance risks Lessons learned Recommended preparation Leveraging technology Background on home health PCR CMS announced it would be implementing a preclaim review demonstration program: Illinois August 1, 2016 Florida October 1, 2016 Texas December 1, 2016 Michigan and Massachusetts January 1, 2017 The demonstration would run through June 30, 2019 Touted as a fraud-fighting technique migrating away from the former pay and chase model 2

3 What is PCR Simply stated, PCR is a process where CMS requires a HH provider to submit documentation, once a home health episode of care has started, but prior to submitting the claim for payment to determine if the documentation is sufficient This is not prior authorization because you initiate service before submitting the PCR Required for each episode of care Components If HHAs did not utilize the PCR process, the claims would be subject to prepayment review After the first 3 months, CMS would reduce the payment by 25% to HHAs that are deemed payable but did not go through PCR The 25% reduction is non-transferrable to the patient It is also not subject to appeal 3

4 Components If a PCR decision is Non-Affirmed, once you submit the claim, Medicare will deny payment The denial will constitute an initial payment decision and the standard claims appeals process will apply Components No new clinical documentation requirements identified PCR request can be submitted anytime after home health services have begun but prior to submission of the final claim If approved, CMS provides a Unique Transaction Number (UTN) to use on claim A provisional affirmative decision only applies to one home health 60 day episode of care 4

5 Components You can resubmit a PCR with additional documentation after receiving a non-affirmation There are no limitations on how many times you can submit Processing Times The MAC will attempt to render a decision within 10 days for initial requests The MAC will attempt to render a decision on subsequent requests with additional documentation within 20 days Steps Affirmed Decision Render Service Submit PCR Request Receive Affirmation with UTN Submit Claim with UTN If all requirements met, claim is paid 5

6 Steps Non-affirmed decision If nonaffirmation is received Submit claim and receive denial OR Resubmit PCR with additional documentation Receive Affirmation Submit claim and receive payment Audits Claims that receive an affirmed PCR will not be subject to additional pre or post payment review Absent evidence of fraud or abuse ZPICs/UPICs and MACs can still perform audits of documentation not required during PCR CERT audits can still occur since they are measuring provider error rates as well as contractor error rates 6

7 Timeline and Current Status PCR began in Illinois on August 3, 2016 Shortly after, CMS indicated additional educational efforts would be helpful and delayed expansion into other states In December 2016, CMS indicated expansion of PCR to Florida in April 2017 April 1, 2017, CMS announced expansion would not take place in FL and would be paused for 30 days in Illinois No substantive updates from CMS have been provided since this time. Update on PCR Demonstration No one knows for sure except CMS They did indicate they would give providers a 30 day notice before moving forward with PCR in the demonstration states There has been no confirmation of expanding PCR to hospice services, but similarities exist so it is a concern 7

8 Affirmation Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Affirmations Partial Affirmations Denial Reasons for HH PCR Skilled nursing services/therapy not medically necessary or documented Homebound status not documented Face-to-face missing/incomplete Other documentation errors Certifications Orders Signatures 8

9 OIG Scrutiny on Hospice January 2015 Medicare Hospices Have Financial Incentives to Provide Care in ALFs Payments for hospice care in ALFs more than doubled in 5 years, totaling $2.1 billion in 2012 Hospices provided care longer and received higher payments for beneficiaries in ALFs than other settings Hospice patients in ALFs had diagnoses that require less complex care. Hospices provided fewer than 5 hours of visits and were paid about $1,100 per week for each beneficiary receiving routine home care in ALFs Also, for-profit hospices received much higher Medicare payments per beneficiary than nonprofit hospices. OIG Scrutiny on Hospice March 2016 Hospices Inappropriately Billed Medicare Over $250 million for General Inpatient Care Hospices billed one-third of GIP stays inappropriately, costing Medicare $268 million in Hospices commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms. 9

10 OIG Scrutiny on Hospice September 2016 Hospices should Improve their Election Statements and Certification of Terminal Illness Hospice election statements lacked required information or had other vulnerabilities in more than one-third of GIP stays. They did not always mention-as required-that the beneficiary was waiving coverage of certain Medicare services by electing hospice care Did not mention that hospice care is palliative rather than curative. In 14% of GIP stays, the physician did not meet requirements-such as composing a narrative-when certifying, and appeared to have limited involvement in determining that the beneficiary was appropriate for hospice care. OIG Scrutiny on Hospice 2017 Workplan Out of only 24 new areas of focus identified across the healthcare continuum, 3 of them were focused on hospice claims. According to IG Daniel Levinson, hospice remains an investigative priority for his agency in

11 OIG Scrutiny on Hospice OEI: Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement: A Portfolio Previous OIG work found vulnerabilities in payment, compliance, and oversight as well as quality of care concerns OIG will summarize all previous OIG evaluations, audits, and investigative work into a portfolio highlighting all key recommendations for protecting beneficiaries and improving the program. OIG Scrutiny on Hospice OAS: W Review of Hospice s Compliance with Medicare requirements OIG will review hospice medical records and billing documentation to determine whether Medicare payments for services were in compliance with Medicare requirements 11

OIG Scrutiny on Hospice OAS: W-00-16-35777 Hospice Frequency of nurse on-site visits to assess quality of care and services In 2013, more than 1.

12 OIG Scrutiny on Hospice OAS: W Hospice Frequency of nurse on-site visits to assess quality of care and services In 2013, more than 1.3 million beneficiaries received hospice from nearly 3,900 hospice providers totaling $15.1 billion in Medicare expenditures. OIG will review requirement that a RN make an onsite visit to the house at least every 14 days to assess quality of care and services rendered by the hospice aide. Ensure services ordered by the hospice interdisciplinary group meet the patient s needs. Common Payment Threats 12

13 Common Errors More detailed analysis of OIG report September 2016 Election Statements 35% of GIP stays election statements lacked required information. Did not specify Medicare 19% Required waiver information was not stated correctly or was missing 12% Required information about palliative care was missing 12% Revocation or discharge information was inaccurate or unclear 4% Common Errors Certifications 14% of GIP stays the physician did not meet the certification requirements and limited involvement in determining the patient was appropriate for hospice 10% the certifying physician did not include a narrative or include diagnosis only 5% the physician did not include an attestation statement 13

14 Common Errors Report on NJ Medicaid hospice (GIP) Medical records did not support terminal illness Medical records did not support the patient status Medical records support long term or custodial care, not Hospice Certification was not timely Employees were not properly licensed or vetted (License verification for professional staff, background checks and LEIE List of Excluded Individuals/Entities) Principal diagnosis on billing claims were dementia, debility and adult failure to thrive. Election Statements To receive services under the Medicare hospice benefit patients (or an authorized representative) must choose hospice care (sign the Election Statement) Each agency develops their own Election Statement 14

15 Election Statements Must include the following: The name of the Hospice providing care to the patient. An acknowledgement that the patient (or authorized representative) has been provided a detailed explanation of hospice care. This must include a clear description of the nature of hospice care and treatment as palliative and not curative in nature. An acknowledgement that certain other Medicare services are waived (not covered) while on hospice care. Election Statements Election date: Must not be prior to the date of election. May be the first day of hospice care or later Designated attending physician must be clearly identified by full name, office address or the National Provided Identifier (NPI) An acknowledgement the attending physician was their choice The signature of the patient (or authorized representative 15

16 Election Statements An election statement missing any one of the required criteria is incomplete and may result in a Medicare denial. Duration of the election is for two consecutive 90- day periods, and followed by an unlimited number or 60-day period as long as the patient meets hospice eligibility: Remains in the care of hospice and is not discharged from hospice Does not revoke election Notice of Election Providers are required to submit a Notice of Election to the Medicare contractor within 5 days Strongly encouraged to submit ASAP Late filing of the Notice of Election will result in provider liable days - Days not paid by Medicare but not billable to the patient 16

17 Notice of Election Exceptions: Data filing issues with the contractor beyond the control of the hospice Newly certified hospice awaiting approval Best Practice: Plan ahead for vacations or illness in staff to be sure the five-day requirement is met Notice of Termination/Revocation (NOTR) Providers are required to file the NOTR within 5 calendar days of the discharge or revocation from hospice unless a final claim has been submitted. 17

18 Physician Certification To qualify for hospice services, the physician must certify the patient has a terminal illness. Certification/recertification are for each benefit period No later than 2 calendar days after the start of each benefit period (initial and subsequent) May be obtained up to 15 days prior to the hospice election and before the start of the next benefit period Written certification must be signed and dated before billing Medicare Physician Certification A statement that the patient has a life expectancy of 6 months or less if the terminal illness A narrative from the certifying physician which includes clinical documentation that supports the patient has a terminal diagnosis. The narrative can be part of the certification form or an addendum. If part of the form it must be located above the physician signature. If an addendum the physician must sign following the narrative. Must include an attestation statement above the physician signature and date stating he/she completed the narrative based on review of the clinical findings in the patient medical record or upon examination of the patient. 18

19 Physician Certification Written Certification (cont.) Benefit period dates Recertification for the third benefit period must include a narrative explaining the findings of a face to face visit that continues to support a life expectancy of less than six months. The narrative must include the date of the visit and an attestation that he/she performed the visit. If the visit was done by a nurse practitioner the must be an attestation the results of the visit were provided to the physician. Common Errors Certifications Predating physician signatures Missing signatures on the initial certification if the patient has an attending physician Missing attestation statement, the certifying physician composed the narrative Missing attestation statements Not having verbal certifications when needed No physician signatures Illegible signatures Missing signature dates Certification period not clearly identified 19

20 General Inpatient Care Provided to hospice patients in need of pain control or symptom management that can t be provided in the home setting It is short term to manage patient symptoms or pain and when under control resume routine hospice care To receive inpatient care, the need must be well documented. Paint the picture of the patient Include details regarding the onset of the uncontrolled pain or symptoms Include the details and outcomes of all treatments tried in the home that were not successful General Inpatient Care Documentation for pain control. Frequency or evaluation by the MD Frequency of medication adjustments IV medications not able to be administered in the home Aggressive pain management Technical complications in medication delivery Documentation for symptom control Sudden and rapid decline that requires intense nursing intervention Uncontrolled nausea or vomiting Pathological fracture Open wounds requiring skilled nursing care Respiratory distressed that can t be managed in the home Delirium 20

21 General Inpatient Care The plan of care must include the changes in the patient s level of care, the patient response to treatments tried and team collaboration with the inpatient staff. The key words are team and collaboration. Documentation Specific Detailed Comprehensive Paint the picture Inclusive of IDT members Deliver on the plan of care Timely Accurate 21

Clinical documentation Contractor Reviews Documents Affirmation Partial Affirmation

and receives payment Non-Affirmed Decision Agency resubmits documentation Agency submits claim,

direct threat to reimbursement Involves a significant change in the intake and billing

22 Hospice PCR? Documentation gathered and submitted to PCR Certification Face-to-face Election Statement Clinical documentation Contractor Reviews Documents Affirmation Partial Affirmation Non-Affirmation Affirmed Decision Agency proceeds to submit claim for current episode with UTN and receives payment Non-Affirmed Decision Agency resubmits documentation Agency submits claim, gets denied, and can appeal Lessons Learned Preparation time Management involvement PCR is a direct threat to reimbursement Involves a significant change in the intake and billing processes, which requires strong guidance and leadership Developing processes and procedures in preparing for PCR Staffing and agency organization Increased workload Develop a team approach with a work plan 22

23 Lessons Learned Training and Education Administrative or billing staff need to be trained on documentation to be submitted and the process for doing so Clinical staff needs to be reminded of the documentation requirements Use language that aligns with CMS rules and guidance But still remember to paint the picture Referral sources need to be trained on their documentation and signature requirements and the process itself Lessons Learned Communication Develop an internal communication plan Sign up for CMS and contractor webinars attend all that you can Create an easy-to-search library of materials for staff Discuss the potential financial impact this could have on the agency 23

24 Lessons Learned Collaboration Work with MAC Request one-on-one education and you ll likely find that you are educating each other Track affirmation rate and reasons for non-affirmations Create a CAP for non-affirmations Lessons Learned Develop an internal risk mitigation plan Obtain face-to-face as quickly as possible Scrutinize referrals more Identify circumstances in which you will not accept referrals Empower intake staff to follow identified protocol Hold physicians and staff accountable What documentation will you require up front? 24

25 Lessons Learned It may not all be bad A majority of industry experts still oppose PCR for various reasons Feedback from some providers was more positive towards the end as MACs simplified processes and more affirmations were being provided Could create better and more efficient processes Staff more educated on requirements Some savvy providers could see this as a business opportunity Less competition More referrals More access to quality staff Lessons Learned Reduces risk of postpayment audits, recoupments, and appeal workload Migrates away from the old pay and chase model which isn t the more efficient model Prior Authorization may delay care Could reduce long-term compliance risks with early identification of common issues 25

26 Leveraging Technology Tracking and reporting Some providers created dashboards tracking the PCRs and results which were reviewed regularly with management team and staff Determine what metrics you want to track or that are important to each member of your implementation team Consider tracking the cycle time and working on reducing that as much as possible Work with your EHR to develop tracking mechanisms Leveraging Technology Utilize an electronic submission process esmd Contractor online process Palmetto eservices NGS Connex CGS My CGS Does your EHR store documents in pdf format? Consider external consultants, partners and vendors who have developed programs to assist in preparing and responding consider a privileged arrangement through counsel 26

27 Recommended Preparation Right now for hospice agencies, monitor what is happening with home health Stay educated and involved Identify potential implementation lead to monitor news and releases Documentation is your only defense in any audit so continue to focus on training and education Quality Assurance Program Consider an external audit or review Assess your policies and procedures Recommended Planning Be proactive in determining if your EHR has capabilities needed for tracking PCRs and identifying what documents are needed and when they are ready to be sent Research potential external partners and vendors and their offerings Review documentation process to see if there are ways in which you can build certain required elements into your referral and reduce multiple documents (signature attestations) 27

28 Recommended Preparation Review election statements to make sure they have all required elements Review physician certifications Review all standard forms Can they be adjusted to assure that all required elements are being obtained Assess your compliance program? Does it have all the required elements? Compliance Programs Dec 2014 CMS expands revocation authority Pattern or practice for billing for services improperly July 2015 DOJ establishes Corporate Counsel Evaluate Compliance Programs April 2016 HHS expands revocation authority Providers who have insufficient or absent compliance program 28

29 Compliance Programs Feb 2017 DOJ published Evaluation of Corporate Compliance Programs Filip Factors for prosecutors 11 Factors Mar 2017 OIG with HCCA releases, Measuring Compliance Program Effectiveness: A Resource Guide 400 unique metrics Today Public/Private Partnership Providers considered negligent Increased penalties for compliance issues Compliance Program Elements 1. Written policies, procedures and Code of Conduct 2. Compliance Officer and/or Committee 3. Training and Education 4. Effective lines of Communication 5. Internal monitoring and auditing 6. Enforcing standards through well-publicized disciplinary guidelines 7. Responding promptly to detected offenses and undertaking corrective action 29

30 Lisa Eick, RN Clinical Consultant (404) , ext 134 Wayne H. van Halem President (404) The van Halem Group A Division of VGM Group, The Details Matter blog.vanhalemgroup.com 30

2017 OIG Work Plan and Current Compliance Topics - Home Health and Hospice

HCCA Web Conference November 20, 2015 2017 OIG Work Plan and Current Compliance Topics - Home Health and Hospice Bill Musick, BS, MBA, CHC, CHCP Senior Associate & Consulting Projects Manager Your trusted