February Hospice Fundamentals All Rights Reserved 2. The Applicable Regulations. 42 CFR 418 Subparts

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Kenneth Wilkins
5 years ago
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1 The Role of the Subscriber Webinar 1 Today s Session The Medicare Regulations Patient Care Payment Understanding and Differentiating the Roles The Medical Director s The Functions Administrative Payment / Eligibility / Relatedness Patient Care / Quality of Care Organizational Checks & Actions of the Prudent 2 A Brief History Very limited role in the first 15 years but growing expectations, particularly related to eligibility/prognosis, starting in the mid 90s Regulatory Response 1997 Operation Restore Trust 2005 Subpart B Admission to hospice care 2009 Subpart B (b)(3) Brief narrative 2011 Subpart B (a) Face to Face Encounter Ordinary and extraordinary entity reviews Relatedness focus Terminal condition Medications 3 All Rights Reserved 1

42 CFR 418 Subparts A. General Provision and Definitions B. Eligibility, Election and Duration of Benefits C. Conditions of Participation Patient Care D.

2 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 Care H. Coinsurance The Applicable Regulations Subpart B Eligibility, Election and Duration of Benefits (Applies to Medicare Patients Only) Certification of terminal illness Admission to hospice care Discharge from hospice care Subpart C CoP Patient Care Subpart D CoP Organizational Environment (Applies to All Patients) Initial and comprehensive assessment Interdisciplinary group, care planning and coordination of services QAPI Licensed professionals Core services Medical director Personnel qualifications All Rights Reserved 2

A Current Tempest: The Whole Versus the Parts Subparts are written / created / monitored by different areas within CMS Subpart B: Payment 418.

3 A Current Tempest: The Whole Versus the Parts Subparts are written / created / monitored by different areas within CMS Subpart B: Payment (c) Sources of certification medical director or physician member of IDG (a) Admission. Admits only on the recommendation of the medical director (d) Discharge. Discharge order from the hospice medical director Subpart D: Organizational Environment Medical Director (b) (c) Certification/recertification. Medical director or physician designee. The Law: 1814(a)(7)of the Social Security Act (the Act) specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual s attending physician, if he/she has one, regarding the normal course of the individual s illness. 11 The Regulatory Division of Roles Medical Director, Designee, & 12 Employment Status Regardless of role, physicians may be Contracted or employed (if allowable in state) Full time Part time May have practice and refer patients Regardless of arrangement, assure that payment for services does not exceed fair market value for time worked 13 All Rights Reserved 3

Administrative Functions The Overlap Billable Patient Care Functions 14 Regardless of Size, 3 Categories of Required Functions Administrative Functions: Medical Director Oversight of medical

4 Administrative Functions The Overlap Billable Patient Care Functions 14 Regardless of Size, 3 Categories of Required Functions Administrative Functions: Medical Director Oversight of medical component Supervision of other physicians Administrative Functions: Payment Evaluation of eligibility at time of admission Certification & Recertification Determination of related/nonrelated Face to face encounters* Patient Care Functions IDG membership Serving as attending* Rounding in hospice facilities* Conducting home or facility visits* Meeting medical need of patients in the event an attending is unavailable or unwilling * OVERLAP: Was billable service provided? includes on its claim Common Models Small One Doc Shop Medical Director Administrative Functions Administration Functions: Payment Patient Care Functions Medium Medical Director + A Few Docs Medical Director Administrative Functions Likely some Administration Functions: Payment Patient Care Functions Few Other Docs Patient Care Functions Administrative Functions: Payment Large Medical Director + Flock of Docs Medical Director Administrative Functions Other Corporate Functions Flock of Docs Patient Care Functions Administrative Functions: Payment 16 All Rights Reserved 4

5 No Matter the Model Only One Medical Director Each CMS Certification Number (CCN) /provider can have only one physician designated to fulfill the role of medical director No other physician has that role Medical Director Responsible for the medical component of the hospice s patient care program Multiple locations Overseeing implementation of the entire physician, nursing, social work, therapy and counseling areas to ensure that the areas consistently meet the patient and family needs Standards Quality 18 Medical Director Designee Assumes the role of medical director in medical director s absence Designated by the hospice Process for physician designation designee means a doctor of medicine or osteopathy designated by the hospice who assumes the same responsibilities and obligations as the medical director when the medical director is not available. [New. Added: 73 FR 32204, June 5, 2008] 19 All Rights Reserved 5

6 If Contracting with a Group Contract must specify the name of the physician who assumes responsibilities and obligations of medical director 20 Job Descriptions/Contracts Clearly identify the designated hospice Medical Director and the designated alternate Medical Director Clearly differentiate medical director roles and responsibilities from the other hospice physicians 21 Titles Supported by Job Descriptions Medical Director Chief Medical Officer Vice President of Medical Affairs Program Medical Director Senior Medical Director Job description would have to clearly spell out this job title means they are the Medical Director Other s Team Associate medical director Job description would read differently than Medical Director 22 All Rights Reserved 6

7 The Medical Director The Medical Director Required Functions Supervision of all hospice physicians Medicare Certifications & Recertifications QAPI Committee or direct QAPI program involvement Frequent Functions Ethics consultations/committee Leadership meetings Compliance committee Education 24 Supervision: Single Site Medical Director Team A Team B Team C 25 All Rights Reserved 7

8 Supervision: Single Site with IPU Medical Director Team A Team B IPU 26 Supervision: Multiple Offices One CCN Medical Director Office 1 Office 2 27 Multiple Locations with Multiple CCNs Corporate Medical Director CCN Medical Director CCN Medical Director CCN Medical Director 28 All Rights Reserved 8

9 How Can Supervision Work Conference calls Meetings E mails Attending team physician IDG meetings Performance evaluations annual and 90 days QAPI Committee Quality outcomes Compliance audit results 29 Medical Director Function 2 Certifications & Recertifications 30 SB13 rb20 SB19 rb26 SB28 rb31 rb Admissions admits a patient only on the recommendation of the medical director, in consultation with, or input from, the attending if they have one. Consideration of terminal condition, other health conditions, current clinically relevant information supporting all diagnoses Not an order It s a process Where and how to document this recommendation All Rights Reserved 9

10 Slide 31 SB13 rb20 SB19 rb26 SB28 rb31 rb34 what about other docs? Susan Balfour, 1/30/2018 unfortuantely only states medical director roseanne berry, 1/31/2018 Is this one of the areas upsetting the RO? so if a CCN has and ADC of 1,500 the medical director would be reviewing all admissions? Not only goofy but impossible. will you be mentioning that in presentation? Susan Balfour, 2/1/2018 no-the RO issue has to do with (b) medical director intiial cert. Bit this is another issue with the regs not being congurent. And it could result in a denial of payment but it hasnt. yet. roseanne berry, 2/1/2018 be ready for question - and why would designee not do this? Susan Balfour, 2/2/2018 okay. i think my response would be this is the way this reg is written which is not in congruence with the cert reg. and has not been an issue to date Other thoughts? roseanne berry, 2/4/2018 hlep on this since it is now under medical director function!!! roseanne berry, 2/6/2018

11 Admissions: How Does It Work for Us? Communication process to hospice physician regarding eligibility Communication to hospice physician of assessments and plan of care Its about eligibility based on patient s eligibility not on what the physician thinks about the complexity of care Medical Director Function 3 QAPI 33 Quality of Care Medical Director as an active participant in QAPI Committee involvement Incidents Medication errors and adverse events Infection CAHPS HIS All Rights Reserved 10

12 Functions 35 One or more of these areas depending on the role Patient care Admissions Eligibility/certifications IDG assessments and care planning Quality of care Education 36 Patient Care Assume role of attending (as needed/requested) Pain and symptom management On call Patient visits Consult with attending physician IDG member 37 All Rights Reserved 11

13 Eligibility Prognostication Certification/recertification Narrative Face to face Communication with attending Terminal and related conditions versus unrelated conditions 38 Initial and Comprehensive Assessment IDG, Care Planning and Coordination of Services Member of IDG Comprehensive assessments Works together to meet the physical, medical, psychosocial, emotional and spiritual needs of patients and families Plan of care establishment and update During meetings Significant changes to POC outside of meetings Coordination of care IDG meetings IDG Meetings Interdisciplinary focus Progress or lack of progress towards the goals Eligibility Teachable moments Not.. Meeting is designed to please the physician Hurried up to fit the lunch hour of the physician 40 All Rights Reserved 12

14 Change in Level of Care Significant change in the POC and therefore all members of IDG should be involved Orders are not required by regulations to change the level of care BUT it is a very good practice and demonstrates hospice physician involvement in the change to the POC (a) Medication Management Medication review (may be done by someone other than the hospice physician who has education and training as defined by hospice policies) Determination of related to terminal condition and all related conditions Address polypharmacy Meet patient needs Appropriateness Financial stewardship Discharges Provides a discharge order when discharge for Moves out of the service area Transfers to another hospice No longer terminal For cause 43 All Rights Reserved 13

15 Patient Visits Management and evaluation Billable Face to Face Administrative If a portion includes management and evaluation services, that portion may be billable QAPI- s Licensed professionals must participate in the QAPI program and hospice sponsored in service training How do you show the participation of hospice physicians? Do the hospice physicians know anything about your QAPI program? 45 CAHPS Getting timely help Help for pain and symptoms Pain Dyspnea Bowels Global Rating of this hospice Willing to recommend this hospice 46 All Rights Reserved 14

16 Item Set Visits When Death Is Imminent Measure 1: % of patients receiving at least 1 visit to address case management and clinical care from a RN, physician, NP or PA in last 3 days of life % of patient stays during which the patient screened positive for dyspnea and received treatment within 1 day of screening % of patient stays treated with an opioid who are offered/prescribed a bowel regimen or documentation of why this as not needed Compliance Program Audits Audit workplan Risk areas Narratives Audit results and performance improvement Documentation of eligibility Face to face Narratives GIP CHC Live discharges Quality of care 48 Compliance Risks Not identifying one physician with the role of medical director Employing or contracting with more physicians than needed to increase referral stream Paying more than fair market value Paying a stipend and not tracking hours worked 49 All Rights Reserved 15

17 Operational Checks Is it clear who is the medical director? How do you demonstrate designated medical director? What is the process which supports the medical director having responsibility for the medical component of the hospice s patient care program? How does the medical director oversee the hospice physician(s)? 50 Operational Checks Is there sufficient physician time at the IDG meetings? What is the process to provide information to the hospice physician regarding assessments and plan of care changes? If the hospice physician is responsible for the ensuring medications meet each patient s needs, how is this accomplished? How is a physician member of an IDG involved in establishing policies governing the day to day provision of hospice care? 51 Be on the Alert s Good understanding of eligibility Commitment to interdisciplinary approach Functions as active member of IDG Visit documentation completed timely Accessibility and responsiveness 52 All Rights Reserved 16

18 Actions of the Prudent Ensure you have answers to the Operational Checks Review how well the role of the medical director is operationalized Listen to the March Webinar The Brief Narrative & The Face to Face Encounter 53 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 17

19 Excerpts: Federal Regulations Medical Directors & s Subpart B: Eligibility, Election and Duration of Benefits (Medicare patients only) Certification of terminal illness Admission to hospice care Discharge from hospice care Subpart C: Conditions of Participation Patient Care (all patients) Initial and comprehensive assessment of the patient Interdisciplinary group, care planning, and coordination of services Quality assessment and performance improvement Licensed professional services Core services Subpart D: Conditions of Participation: Organizational Environment (all patients) Medical director Personnel qualifications

April Hospice Fundamentals All Rights Reserved 1. The Certification/ Recertification Process: No Room for Error. What You Will Learn Today

April Hospice Fundamentals All Rights Reserved 1. The Certification/ Recertification Process: No Room for Error. What You Will Learn Today The Certification/ Recertification Process: No Room for Error Subscriber Webinar What You Will Learn Today Regulatory requirements Election of the Medicare Hospice Benefit Certification Recertification