Keeping an Eye on the Hot Topics to Ensure Compliance

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Keeping an Eye on the Hot Topics to Ensure Compliance Annette Kiser, MSN, RN, NE-BC Chief Compliance Officer September 13, 2017 Topics for Discussion 2 Current agencies with an eye on hospice Hospice Quality Reporting Program updates Common risk areas in processes and documentation Strategies to help reduce the risk of noncompliance 3 WHOSE EYES ARE WATCHING? All Those Acronyms 9/13/2017 1

CMS Contractors MAC Medicare Administrative Contractor CERT Comprehensive Error Rate Testing Contractor RAC Recovery Auditor *ZPIC Zone Program Integrity Contractor *MIC Medicaid Integrity Contractor *UPIC Unified Program Integrity Contractor - New! 4 New Entity UPIC 5 Combines the work of the following: o ZPIC (Medicare) o MIC (Medicaid) o Program Safeguard Contractors (PSCs) o Medicare-Medicaid Data Match (Medi-Medi) Focus: Fraud, waste and abuse South Eastern Region contract in process o Will cover NC, SC, GA, AL, FL, TN, VA, WV, Puerto Rico, Virgin Islands New RAC 6 Single auditor for hospice, home health & DME o Performant Recovery Inc. Covers all states Higher likelihood of hospices being audited Working with CMS for approval of issues Outliers will be the first audited 2

Investigators Office of Inspector General (OIG) o May be focused on entire industry or a single hospice Department of Justice (DOJ) o Investigations are provider specific Federal Bureau of Investigation State Bureau of Investigation State Attorney General 7 Contractor Audits 8 Purpose To ensure that coverage, coding, and medical necessity requirements are met Automated Reviews Based on claims data with no review of medical records Complex Reviews Medical records audited Type of Review On-site, via mail, or combination Results Timeframes 30 days to years Appeals All denials can be appealed Other Auditors & Surveyors 9 Third Party Payers o Private Insurance o Veterans Administration (VA) o TRICARE State Medicaid Agencies o Program specific o Usually post-payment audits Medicare Certification Surveyors o Visit every 3 years o Assess Medicare Conditions of Participation compliance 3

Records Reviewed Depending on auditor, review can include clinical, billing and administrative records and policies o Medical records o Admission and referral policies o Billing records o Census data o Billing policies o Personnel files o Contracts with facilities and physicians 10 Why Am I Being Audited? 11 Data Analysis Outlier compared to peers o Aberrant billing patterns o PEPPER data o Aggregate cap issues Complaints Anyone can voice concern o Patient/family o Competitor o Anonymous source Whistleblower Former employee Referral Survey or contract agency Clinical Denial Reasons 12 Eligibility Documentation doesn t support 6 months or less prognosis Higher Level of Care Documentation doesn t support use of GIP or CHC Physician Narrative Statement Inadequate Plan of Care Review not documented for all dates IDG Involvement Lack of evidence to show core disciplines participated in POC review 4

Technical Denial Reasons 13 Physician Certification Invalid or missing Election Statement Untimely or missing required elements Face to Face Missing or untimely Automatic Denial Failure to submit records Medical Necessity 14 Payment cannot be made for hospice care that is not reasonable and necessary for the palliation or management of terminal illness o Per Social Security Act Sec. 1862 (a)(1)(c) Documentation must show that care is needed Medical Review Results 15 Discrepancies in documentation o FAST or PPS scores not supported by clinical notes o Inconsistent documentation of weights, mid-arm circumference o Oxygen use varies with no explanation o Inconsistencies in how various disciplines describe the patient s condition Medication therapy is not maximized and no rationale is noted, e.g., with COPD or CHF Symptoms are not related to hospice diagnoses 5

Federal Audit Findings Alzheimer s disease Cachexic with a 25.1 lb. weight loss in past 6 months and 6.7 lbs. were in the past month BMI decreased from 25.6 to 21.6 Left mid-arm circumference (MAC) was 24 cm, muscle wasting noted Staff noted slow decline in cognition and ADLs Oriented to self, forgetful, able to follow commands and unable to make needs known Difficulty swallowing noted; but no signs or symptoms of aspiration, diet changed to pureed, appetite good and no nutritional needs were identified 16 Federal Audit Findings #2 17 Documentation did not support inability to maintain sufficient fluid and calorie intake or progressive malnutrition A recent fall noted without injury, had history of falls, ambulation unsteady Beneficiary able to respond to questions No intractable pain or skin breakdown No recurrent hospitalizations or emergency room visits Although the beneficiary is in need of custodial care the documentation did not show a significant continued decline in medical condition. Documentation does not support clear evidence of decline. OIG Focus on Hospice 18 Issued two reports in 2016 o Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care March o Hospices Should Improve Their Election Statements and Certifications of Terminal Illness September Include recommendations to CMS o Increase GIP claims oversight o Strengthen surveys, particularly related to plan of care o Establish additional enforcement remedies Led to CMS releasing guidance on certification and election statements 6

OIG FY2017 Work Plan Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement: A Portfolio Review of Hospices Compliance with Medicare Requirements Hospice Home Care Frequency of Nurse On-Site Visits to Assess Quality of Care and Services Other Future Plans Additional oversight of hospice care, including oversight of certification surveys and hospice-worker licensure requirements 19 New Work Plan Items 20 OIG has decided to update their work plan ongoing and not just annually Two new hospice items added this summer o Trends in Hospice Deficiencies and Complaints o Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims Strategies for Success 21 Educate staff on documentation o Support eligibility at admission and ongoing o Support higher levels of care every day o Record aide supervision every 14 days Review care planning processes o Involve full IDG even if not assigned to the patient o Include scope, frequency, interventions and outcomes Review GIP utilization o Must document interventions tried prior to GIP transfer o Include hospice MD & attending MD o Review records, especially longer stay patients 7

More Strategies Review election statements o Confirm all required elements are present o Ensure it is clear what benefit is being elected Review certification process o Document communication with hospice medical director and attending physician o Document clinical information from outside sources Audit claims and invoices o Ensure consulting MDs are billing hospice, not Part B 22 Be Audit Ready! Define your Audit Response Team Managers Compliance Admissions Medical records Billing Legal counsel Educate staff on the audit process How to respond during interviews Medical record submission process 23 24 CMS SPEAKS FY 2018 Final Rule 9/13/2017 8

Financial Aspects Rate Increase 1% for the fiscal year Aggregate Cap Amount $ 28,689.04 Cap Accounting Year Aligned with Federal Fiscal Year 10/1-9/30 Cap Self-Report Due February 28, 2018 earlier date 25 Clinical Information for Certification Complaints Patients and ombudsmen complain that only information from hospice is in the patient s record Concerns Short stay patients may not be seen by the certifying MD Referrer Who decided the patient was appropriate for hospice and what did they use for that determination? Sources Include clinical information from community providers in addition to hospice staff o Referring physician o Acute care facility o Post-Acute care provider 26 CMS Action 27 States admission assessment should not be basis for certification o Hospice documentation helps substantiate eligibility based on other clinical information No regulatory change at this time Will ensure that the Medicare Administrative Contractors (MACs) request clinical documentation used for eligibility when conducting medical review 9

28 DATA ANALYSIS 9/13/2017 Data Monitoring LOS 29 Overall Length of Stay FY 2016 o Single hospice election 79 days o Average lifetime 96.1 days o Median 18 days LOS by Diagnosis at Routine Home Care Level FY 2015 o Neurological Diagnoses 165.3 days o Cancers 63.7 days o Heart 115.14 days o Lung 122.1 days o All Diagnoses 113.5 days Live Discharge Data 30 FY 2016 17 % of beneficiaries discharged alive Reasons: o 38% Revocation o 51% No longer terminally ill o 11% Transfer Length of Stay for Discharges o 0-30 days 26% o 31-60 days 13% o 61-90 days 14% o 91-180 days 19% o 181+ days 28% No anomalies identified Monitoring will continue to identify any concerning behavior in response to payment reform 10

Skilled Visits Data Analyzed Skilled Visits in the Last Days of Life for FY2016 On any given day during the last 7 days o 46.5% of patients did not have a skilled visit from a RN o 89.6% of patients did not have a skilled visit from a SW 21% patients did not receive a skilled visit on day of death CMS does not see behavior changes among hospices when compared to time periods prior to policy reform implementation 31 Spending Outside of Hospice 32 Ongoing concerns based on FY 2016 data o Medicare paid $900+ million for services under Parts A, B, D during hospice election CMS says unusual and exceptional to see services provided outside of hospice at the end of life Analysis suggests unbundling of items and services is taking place Medicare may be paying twice once to hospice and once to other providers Non-Hospice Spending 33 Beneficiaries should not have to routinely seek items, services, and/or medications beyond those provided by hospice Parts A and B Amounts have declined, but are still significant o FY 2012 $747.9 million o FY 2014 $624.2 million o FY 2016 $534.5 million Plus $129.6 million paid by beneficiaries 11

Non-Hospice Spending Part D Amount paid by Medicare has increased o FY 2012 $331.3 million o FY 2014 $294.0 million o FY 2016 $347.5 million Plus $64.9 million paid by beneficiaries Most drugs should be covered under the Part A hospice benefit o Palliative and other disease-specific drugs o Maintenance drugs that may offer symptom relief Such as those used to treat blood pressure, heart disease, asthma, and diabetes 34 Actions to Take 35 Tighten process for hospice MD to document unrelated medications, treatments and services Educate consulting physicians to bill hospice if care is related Communicate with Part D plan sponsors to ensure billing is accurate (A3 Reject Form) Educate patients that no related medications can be billed to Part D Review invoices to ensure care and medications are billed to hospice 36 HOSPICE QUALITY REPORTING Current and Future Measures 9/13/2017 12

Composite Process Measure 37 Hospice and Palliative Care Composite Process Measure Comprehensive Assessment at Admission Uses the 7 Hospice Item Set measures to calculate a composite score Calculation based on number of patients with all 7 measures documented o Lowest score is Pain Assessment Individual components scored separately and then aggregated into one score Hospice Visits Paired Measure Implemented April 1, 2017 Applicable only to Routine Home Care patients Visits only not phone calls Report on HIS Discharge form, the level of care and number of visits in last 7 days of life o At least 1 visit from RN, MD, NP or PA in the last 3 days of life o At least 2 visits from MSW, Chaplain, LPN, or Hospice Aide in the last 7 days of life Data analysis being conducted so not reported yet 38 Actions to Take Review Analyze Review HIS reports to determine gaps in collection Ensure admission processes capture all HIS items Pay attention to patients who live only few days Analyze data on visits made in last 7 days # of RN, NP or MD visits in last 3 days? (1) # SW, Chaplain, LPN or aide visits in last 7 days? (2) Are patients receiving less care on the weekends? Submit Ensure 90% of HIS records are submitted timely Effective January 1, 2018 39 13

Hospice CAHPS No changes for FY 2018 Top-box scoring methodology is used CMS will level the playing field by using two kinds of adjustments to the data o Case-mix adjustments Based on decedent and caregiver characteristics Length of Stay, Primary diagnosis, Age of decedent & respondent, Respondent s education level, etc. o Mode adjustments Based on telephone, mail, or mixed mode of administration 40 Actions to Take 41 Ensure data is submitted timely by vendor and accepted by data warehouse Review CAHPS reports o Address significant changes in scores Use language of CAHPS in conversations with patients and families o Cannot ask them to rate care in a certain way o Cannot use similar questions in another survey tool Hospice Compare 42 Website launched in August Reports percentiles of 7 HIS measures Refreshed quarterly CAHPS measures to be added in winter 2018 o Data will be reported using a rolling 8 quarter average Star ratings will be added in the future 14

Potential Future Measures CMS plans to continue to explore adding other measures to assess hospice quality Claims Based Measures are being evaluated These would require no extra work for hospices since the information comes from claims Would allow comparison of providers to their peers o Relevant and available patient-level and hospicelevel factors can be taken into account 43 Measures Being Considered 44 #1 Potentially avoidable hospice care transitions o Concern with hospice discharge, expensive hospital admission, and then hospice readmission in a short time o Transitions are burdensome to patients, families, and the health care system Measures Being Considered #2 Access to all levels of care o Full access to 4 levels can lead to cost savings & increased patient and caregiver satisfaction o Measure can increase patient access to various levels Continuous Home Care 0.27% of all hospice days in FY16 Not billed by more than 50% of hospices Respite 0.31% of all days General Inpatient Care 1.4% of all days Reminder all hospice agencies regardless of size, location or other organizational or market characteristics must be able to provide all four levels of hospice care Required per CoPs 45 15

Actions to Take Analyze dischargereadmission data Why did discharge occur prior to hospital stay? In hindsight, could discharge have been avoided? Review agency data to ensure provision of all 4 levels of care are provided Document efforts to obtain contracts Continue to make attempts with various facilities Document instances of CHC being provided, but not billable Maintain staff to provide CHC develop prn pool 46 Tool Under Development 47 HEART Hospice Evaluation & Assessment Reporting Tool o Comprehensive patient assessment tool will incorporate medical, psychosocial, spiritual and other aspects of hospice care o Will replace the Hospice Item Set o Will complement, but not replace, initial and comprehensive assessments CMS working with clinical experts in hospice, CMS and HHS to collect input Technical Expert Panel (TEP) being formed Testing will occur before implementation 48 OTHER TOPICS FOR ALL PROVIDERS 9/13/2017 16

Drug Education & Disposal Changes in statute in both NC and SC Strengthen Opioid Misuse Prevention (STOP) Act NC statute enacted July 1, 2017 o Hospice & palliative care must provide education on drug disposal to include take back programs o Applies only to CII or CII narcotics and opioids o Requires electronic prescribing by January 2020 o Allows distribution of naloxone by organizations with a standing order o No change in disposal regulations 49 Drug Disposal 50 SC Quality Hospice Programs Act May 2017 o Statute allows hospice nurse to dispose of unused controlled substances o Record name and quantity of all drugs o Hospice nurse can conduct immediate disposal at the site of care in the presence of a witness who signs to confirm witnessing occurred o Or can utilize mail-back to a registered collector nurse deposits meds in the envelope and seals it and takes it to o Record the method of disposal in the medical record Nondiscrimination Rule 51 Nondiscrimination in Health Programs & Activities Health Equity Rule published by OCR Was effective November 2016 If more than 15 employees, must have civil rights grievance procedure and designated compliance coordinator Language access plan can be beneficial o Address interpreter and communication options 17

Nondiscrimination Rule Nondiscrimination Notice must be posted and added to significant publications and communications Taglines in top 15 non-english languages must accompany notice o Add to website, admission packet, marketing materials, bereavement mailings o For small publications, can do a statement and top 2 languages Must provide access to qualified interpreters 52 Emergency Preparedness Rule 53 CMS rule that applies to 17 provider types November 15, 2017 Required implementation date Addresses 4 practice standards o Emergency Plan o Policies and Procedures o Communication Plan o Training and Testing Program Initial and annual tests Added new Condition of Participation for hospices at 418.113 Emergency Preparedness Rule 54 Conduct a Hazard Vulnerability Analysis consider all natural and manmade emergencies and disasters Update emergency plan to address all requirements Develop a plan to ensure communication with staff, patients, & local and regional emergency personnel Conduct a tabletop exercise and a communitybased exercise by 11/15/17 Educate staff on the emergency plan and communication plan 18

55 PALLIATIVE CARE 9/13/2017 OIG FY2017 Work Plan 56 Physician Home Visits Reasonableness of Services o Will determine if Medicare payments for Evaluation & Management home visits were reasonable and necessary o MD must document the medical necessity of a home visit Prolonged Services Reasonableness of Services o Will determine if Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements o Necessity is considered to be rare and unusual o Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.1 outlines requirements that must be met in order to bill for a prolonged E/M service code Palmetto GBA Activity Palmetto GBA is producing electronic Comparative Billing Reports (ecbrs) Focus is on Evaluation & Management (E/M) services and compliance with coverage and documentation requirements Current ecbrs: o New Patient Office Visit CPT Codes 99201-99205 o Established Patient Office Visit 99211-99215 o Subsequent Hospital Visit CPT Codes 99231-99233 19

New Part B Probe Edit 8/1/17 Palmetto GBA posted a medical review edit Prepayment Service Specific Probe Review Notice for Subsequent Nursing Facility Care o CPT Code 99309 Typically 25 minutes per day o CPT Code 99310 Typically 35 minutes per day o Applies to North Carolina, South Carolina, Virginia and West Virginia Based on internal data analysis and prioritization, which identified these CPT codes as a major risk Will select a sample of 100 claims from each state 58 Provider Actions 59 Review Comparative Billing Reports and determine any areas needing attention Audit E/M services on regular basis pre-bill is best practice Review statistical debriefing information and other resources published with CBRs Monitor DDE to determine if ADRs are posted on claims Quality Payment Program 60 New Quality Payment Program (QPP) for physicians effective 1/01/17 Applies to those who bill Medicare more than $30,000 a year and provide care for more than 100 Medicare patients a year Two options are available MIPS or APM Data must be reported by March 31, 2018 to be accepted 20

Quality Reporting MIPS Must report on at least one measure on one patient for 2017 to avoid a penalty o Can choose to participate for the final 90 days of the calendar year for a potential positive payment adjustment Some have the option to participate in an Advanced Alternative Payment Model (APM) o Successful participation could lead to as much as a 5% incentive payment in 2019 61 Provider Action 62 Participate in CMS education Review resources on Quality Payment Program website Use features of website to test measures available to determine how to best achieve requirements Develop implementation plan to decide when to begin reporting 63 RESOURCES Innovation 9/13/2017 and Excellence in Advanced Illness at End of Life 21

CMS Resources FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements https://www.gpo.gov/fdsys/pkg/fr-2017-08- 04/pdf/2017-16294.pdf Hospice Quality Reporting Program https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/Hospice-Qualityreporting/ 64 Audit Contractors 65 Review Contractor Directory Interactive Map https://www.cms.gov/research-statistics-data- and-systems/monitoring-programs/medicare-ffs- Compliance-Programs/Review-Contractor- Directory-Interactive-Map/ Performant Recovery RAC https://performantrac.com/region-5/ OIG Documents 66 OIG Report: Inappropriate Billing of GIP Care (OEI- 02-10-00491) http://cchospice.org/wp- content/uploads/2016/04/oig-report-hospice- Inappropriate-GIP-Care-TCC-Summary-04.01.16.pdf OIG Report: Issues with Election Statements and Certifications of Terminal Illness (OEI-02-10-00492) https://oig.hhs.gov/oei/reports/oei-02-10- 00492.pdf OIG Work Plan 2017 https://oig.hhs.gov/reportsand-publications/workplan/ 22

HQRP Resources HIS Technical Information Webpage https://www.cms.gov/medicare/quality-initiatives- Patient-AssessmentInstruments/Hospice-Quality- Reporting/HIS-Technical-Information.html HIS Education & Resources (QTSO webpage) https://www.qtso.com/hospice.html CAHPS Hospice Survey Website http://www.hospicecahpssurvey.org/ 67 Other Resources 68 Nondiscrimination Rule (Section 1557 of the ACA) Resources http://www.hhs.gov/civil-rights/forindividuals/section-1557/index.html Emergency Preparedness Rule https://www.gpo.gov/fdsys/pkg/fr-2016-09- 16/pdf/2016-21404.pdf Palliative Care Resources 69 Palmetto GBA ecbr Information https://www.palmettogba.com/palmetto/providers.nsf/docscat/providers~jm%20part%20b~eservices %20Portal~eCBR Comparative Billing Reports & Resources http://www.cbrinfo.net/ Quality Payment Program Website https://qpp.cms.gov/ 23

Audit Preparation Resources Hospice Law Library Articles http://www.reinhartlaw.com/hospice-lawlibrary/essential-tools-for-your-right-hand-drawer/ Checklist for Hospice Audit Interviews and Conferences http://www.reinhartlaw.com/wp- content/uploads/2016/08/checklist-audit- Interviews.pdf 70 71 800.662.8859 www.cchospice.org 24