Hospice and the Letter People: Who Are They & What Do They Want?

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Tamsyn Boyd
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1 Hospice and the Letter People: Who Are They & What Do They Want? Subscriber Webinar Plan for the Webinar Meet the 4 Faces of Medicare Discuss responsibilities of each & how to get information Consider internal knowledge & process needs related to building regulatory competency All Rights Reserved 1

2 The First Step in Compliance Knowing with what you are supposed to be complying Why Do We Do What We Do? Regulation Actual Regulation Mythical Regulation Surveyor Suggestion Regulation Someone Else's Accreditation Standards Professional Standards Agency Policy Agency Tradition We ve always done it this way. All Rights Reserved 2

The Regulations Are the rules that carry out a statute Address provision of care and payment Define the minimum requirements a provider must meet to participate in the Medicare program Are designed

3 The Regulations Are the rules that carry out a statute Address provision of care and payment Define the minimum requirements a provider must meet to participate in the Medicare program Are designed to protect consumers As advocates for hospice care, it is important to understand what the rules say, how they are applied and, if they don t work, how to effect change 9 42 CFR 418 Subparts A. General Provision and Definitions B. Eligibility, Election and Duration of Benefits C. Conditions of Participation Patient Care D. Conditions of Participation Organizational Environment E. Conditions of Participation Removed and Reserved F. Covered Services G. Payment for Hospice Care H. Coinsurance All Rights Reserved 3

4 The Four Faces of Medicare Centers for Medicare and Medicaid Services CMS Part of the US Department of Health and Human Services DHHS Created in March 1977 to administer Medicare and Medicaid Formerly know as the Healthcare Financing Administration HCFA Central office CO is in Baltimore; 10 regional offices ROs around the country All Rights Reserved 4

5 CMS Responsibilities 1. Establish provider standards 2. Monitor provides to assure that they are meeting the standards and to take action if they are not 3. Assure that providers are properly paid for services provided 4. Provide a process for beneficiaries to appeal provider decisions All Rights Reserved 5

Establish Provider Requirements Promulgate regulations based on statute Rules for Part A providers are known as Conditions of Participation CoPs Conditions of Payment The Rule Making

6 Establish Provider Requirements Promulgate regulations based on statute Rules for Part A providers are known as Conditions of Participation CoPs Conditions of Payment The Rule Making Steps Proposed Rule Released and Published in Federal Register Sixty Day Comment Period CMS Reviews Comments Final Rule Issued with Implementation Dates for Any Changes All Rights Reserved 6

7 The Enduring Life of a Final Rule The final rule creates an enduring record that may be used by many parties in the future Comments count CMS has to read every comment and respond in the final rule Volume of comments is noted Provides an opportunity to introduce new perspectives, suggest possibility of unintended consequences and to tactfully question assumptions State Survey Agencies Survey and Certification S&C works with State Agencies SAs to monitor performance via the survey process Certain % of providers as specified by CMS are surveyed each year or following complaints If deficiencies are found, SA follows up to determine if they have been corrected or not By law, surveys must be unannounced All Rights Reserved 7

8 Deemed Status Surveys Surveys may also be conducted by an Accrediting Organization (AO) However, there is an alternative to SA surveys for demonstrating compliance with the applicable CoPs. Accreditation based on a survey by a CMS approved Medicare accreditation program may be used by CMS to deem a provider or supplier as complying with the applicable regulatory standards. State Operations Manual (Chapter 1) TJC CHAP ACHA The Joint Commission Community Health Accreditation Partner Accreditation Commission for Healthcare Medicare Surveys Surveys are conducted using 1. Subparts C & D of the hospice regulations the COPS and the Interpretive Guidelines the IGs 2. State Licensure Rules 3. The hospice s own policies The CoPs apply to all patients for whom the hospice provides care regardless of payor source All Rights Reserved 8

9 State Licensure Rules Co exist with the CoPs; if both address a particular area, the higher standard prevails Are state specific and vary from state to state (a few states do not have any) Each state has own licensure survey frequency If relocating to a new state, be aware that new licensure rules will apply Reading the Conditions of Participation L520 L521 L Tag Condition of Participation Interpretive Guidelines Condition of participation: Initial and comprehensive assessment of the patient. The hospice must conduct and document in writing a patient specific language comprehensive assessment that identifies the patient s need for hospice care and services, and the patient s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Used to identify and organize deficiencies The actual regulatory Interpretive Guidelines The comprehensive patient assessment must accurately reflect the patient s current health status Guidance for surveyors and and include information to establish and monitor a plan of invaluable care. Hospices for are providers. not required Read to use specific forms or formats side by side to document with their initial CoPsor comprehensive assessments. They may choose to document patient specific comprehensive assessments in either written or electronic format provided the assessments Additional are complete, Source readily of identifiable Suband available in Regulatory the patient s Information: clinical record. The CMS On Line Only Manual System All Rights Reserved 9

10 Medicare Administrative Contractors The MACs Have been also been called Regional Home Health and Hospice Intermediaries RHHIs and Fiscal Intermediaries FIs Contract with CMS to process Medicare claims By law must be non governmental entities Performance assessed regularly by CMS and Office of the Inspector General OIG Contractor Error Rate Testing process CERT an addition means of performance assessment Review and make payment decisions based on Subparts B and the Conditions of Coverage and other information found in Subpart F Requirements for Coverage To be covered, hospice services must meet the following requirements. 1. They must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions. 2. The individual must elect hospice care in accordance with Sec A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice program as set forth in Sec The plan of care must be established before hospice care is provided. 5. The services provided must be consistent with the plan of care. 6. A certification that the individual is terminally ill must be completed as set forth in Sec All Rights Reserved 10

Subpart B: The Technical Coverage Provisions Requirements that apply to Medicare patients only Certification Election / Revocation Admission / Discharge Transfers

11 Subpart B: The Technical Coverage Provisions Requirements that apply to Medicare patients only Certification Election / Revocation Admission / Discharge Transfers Eligibility Other MAC Functions Provider education Claims review Hospice cap calculations Processing changes in provider information Beneficiary services All Rights Reserved 11

12 The Hospice MACs 1. Palmetto Government Benefits Administrators PGBA 2. Cahaba Government Services CGS 3. National Government Services NGS 36 The Medicare QIOs Formerly known as Peer Review Organizations, the PRO, now known as Quality Improvement Organizations QIOs Non profits; up until 2014 re organizations one in each state Hospices interact with them when issuing a notice of Medicare Non Coverage NOMNC as part of the Expedited Determination Process Part of Beneficiary Notice Initiative BNI; information is found in Chapter 11 of the Claims Processing Manual regulations and at link below rather than with the rest of the hospice regulations General Information/BNI/index.html All Rights Reserved 12

13 Post-Reorganization BFCC QIOs Beneficiary and Family Centered Care Quality Improvement Organizations carry out the case review function and will handle all first level beneficiary appeals resulting from hospice discharges for ineligibility. QIN QIOs Quality Innovation Network Quality Improvement Organization will be responsible for working directly with providers and communities on quality initiatives. Hospices can expect to have more interactions with these in upcoming years. A Note on Medicaid Medicaid hospice benefit is almost identical to HMB No separate provider certification process States have separate reporting rules No routine survey visits States may process claims themselves or work with fiscal agents All Rights Reserved 13

14 Available Resources Medicare Internet Only Manuals CMS program issuances, day to day operating instructions, policies, and procedures Based on statutes, regulations, guidelines, models, and directives Used by providers, contractors, Medicare Advantage organizations and state survey agencies to administer CMS programs Organized by function rather than by provider Of most interest to hospices Benefit Policy Manual Chapter 9 State Operations Manual (Surveyor Interpretive Guidelines Appendix M) Claims Processing Manual Chapter 11 Benefit Integrity Manual All Rights Reserved 14

15 CMS Program Transmittals Vehicle used to communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS program manual Cover page (or transmittal page) summarizes the change Each has both a transmittal and a change request number; the latter is what they are commonly referred to as Material ultimately added to the manual identified on transmittal page Medicare Learning Network will also issue an MLN Matters article on new information; usually a bit easier to understand but not always exactly correct When Questions Arise All Rights Reserved 15

16 Next Time You Hear Because Medicare... Ask yourself Which face of Medicare said it? Where and when? Has it been superseded? Are my circumstances the same or similar? Is there another regulatory body with which to check? If Medicare is silent on the topic, does my agency have a policy that addresses it? Questions about Patient Care? Social Security Act Conditions of Participation Interpretive Guideline Medicare Internet Only Manuals Accreditation Standards Occupational Licensing Boards State Licensure Rules Transmittals / Change Requests Agency Policies Broader Issues Decision All Rights Reserved 16

17 Payment Question Route Who s Paying? Medicare Eligibility Subpart B (sometimes F as well) Medicare Manuals Transmittals / Change Requests Check with MAC Medicaid Eligibility Medicaid Manuals Check with State Agency Private Insurer Contract Check with case manager or customer service Self Pay Agency Policy When Addressing Questions Many questions have no black and white answer learn to appreciate that grey gives you more room Must establish a process if you want some measure of consistency Reasonable people can and will disagree don t take it personally Everyone should be expected to defend his/her position and back it up with evidence Every action (or inaction) sets a precedent Lively debate will definitely ensue All Rights Reserved 17

18 Considering New Regulations Cracking the Regulatory Code History what brought this on? Intent what change is the regulation intended to make? Why? Supporting Rationale if a change that is published in the Federal Register, what does the narrative say? Impact who in my hospice will be impacted? Which face of Medicare will monitor? What are the risks of under compliance or non compliance? What would over compliance look like? All Rights Reserved 18

19 Building Regulatory Competence 1. Defined expectations of regulatory knowledge by position 2. Assigned responsibility for monitoring regulatory changes 3. Plan for teaching regulatory content in orientation and at regular intervals Building Regulatory Competence 4. Plan for communicating changes at appropriate levels 5. An internal process to use when there is no answer 6. Ability to assess risk of any action or inaction All Rights Reserved 19

20 To Contact Us Susan Balfour Roseanne Berry Charlene Ross The information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. All Rights Reserved 20

The Four Faces of Medicare State Survey & Certification Agencies Monitor providers to assure that they are

paid for services SUBPARTS B, F & G Medicare Administrative Contractors Quality Improvement Organization

Federal Regulations Title 42, Volume 2, Parts 400 to 429 PART 418 HOSPICE CARE 42 CFR 418 Subparts A.

Conditions of Participation Patient Care D. Conditions of Participation - Organizational Environment E.

21 The Four Faces of Medicare State Survey & Certification Agencies Monitor providers to assure that they are meeting the standards SUBPARTS C & D ROs Centers for Medicare & Medicaid Services Assure that providers are paid for services SUBPARTS B, F & G Medicare Administrative Contractors Quality Improvement Organization Provide a process for beneficiaries to appeal provider decisions CMS BENEFICIARY NOTICE INITIATIVE Code of Federal Regulations Title 42, Volume 2, Parts 400 to 429 PART 418 HOSPICE CARE 42 CFR 418 Subparts A. General Provision and Definitions B. Eligibility, Election and Duration of Benefits C. Conditions of Participation Patient Care D. Conditions of Participation - Organizational Environment E. Conditions of Participation Removed and Reserved F. Covered Services G. Payment for Hospice Care H. Coinsurance visit or call us at

October Hospice Fundamentals All Rights Reserved 1. ABNs: The Why, The What & The When. The Plan

October Hospice Fundamentals All Rights Reserved 1. ABNs: The Why, The What & The When. The Plan ABNs: The Why, The What & The When Subscriber Webinar The Plan CMS Benefit Notices Initiative The Advance Beneficiary Notice of Noncoverage (ABN) The Uses: Statutory & Voluntary The Form The Difficulties