Hospice Coalition. Questions and Answers

Hospice Coalition Questions and Answers September 9, 2009

To: Hospice Coalition Members From: Palmetto GBA Provider Education Date: September 9, 2009 Location: Palmetto GBA Attachment AD: Palmetto GBA Hospice Cap Overpayments by State Attachment A 2004 Attachment B 2005 Attachment C 2006 Attachment D 2007 PAYMENT, BILLING, COVERAGE 1. We have been advised from Palmetto GBA benefits connect that they will no longer remove MSP from the patients file if the hospice sends Palmetto GBA a denial from that MSP stating that Medicare is primary. We have been told that the patient or POA has to contact the benefits connect line with an end date for the MSP before it will be removed. Can you please elaborate why a denial from the MSP is not considered appropriate? All Medicare Secondary Payer (MSP) records are maintained by the Coordination of Benefits Contractor (COBC). Palmetto GBA is not authorized to make updates or effectuate the MSP records. If a MSP record exists in the Common Working File (CWF) for a beneficiary that is incorrect or needs a termination date added, the request must be sent to the COBC. In some instances, the COBC may require that the beneficiary or authorized representative contact them to make the necessary updates. The COBC can be contacted at (800) 9991118. More information about the COBC can be found on the CMS Internet Web site at www.cms.hhs.gov/cobgeneralinformation. With regards to claims that are submitted to Palmetto GBA for processing, when a valid MSP record exists on the CWF, all appropriate codes must be present on the claim to process it for secondary payment consideration or, if applicable, a conditional payment in which case a conditional payment Hospice Coalition Q & A 1

request form must be submitted to Palmetto GBA. A blanket denial from the primary insurance is not acceptable unless it meets the criteria for requesting a conditional payment, which are explained on the conditional payment request form (Attachment A). 2. If a Medicare Hospice recipient decides to revoke the benefit because they want to go to the hospital for aggressive care, can the hospice readmit that patient once they are discharged from the hospital (if they are eligible for service, of course) or does the patient have to wait until the start of their next benefit period? (This question is being generated due to a state s interpretation of the Medicare rules that a patient is only eligible for hospice admission once during each benefit period. They plan to initiate this process starting October 1 with their Medicaid program.) A beneficiary may choose to revoke the Medicare hospice benefit at any time. To revoke the benefit, the beneficiary must file a signed statement that he or she no longer wishes to receive Medicare coverage of hospice care for the time remaining in that election period. This statement must also include the date the revocation is effective. Any days remaining in the benefit period will be forfeited. The beneficiary may re elect the hospice benefit at any time, and are not required to wait until the start of the next benefit period. However, hospice beneficiaries should be advised that any remaining days from the previous benefit period, were forfeited; thus, a new benefit period would begin. Reference: Centers for Medicare & Medicaid (CMS) Internet Only Manual (IOM) 10004, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services under Hospital Insurance, Section 20.2 Election, Revocation, and Change of Hospice. 3. On the electronic claim, the ANP is listed in the other physician field as the attending. Where should the attending physician be listed on the claim, as the Medical Director, or is it left blank? Please provide a review of the fields that the ANP should be listed in and which fields to list the attending physician and the Medical Director? The other physician field (Field Locator 79 on the UB04 Claim Form) is the correct field to enter the National Provider Identifier (NPI) for a Nurse Practitioner who has been selected by the beneficiary as his/her attending physician. The NPI for the medical director is entered in the Attending Physician field (Field Locator 76 on the UB04 Claim Form). This requirement is defined in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual, Publication 10004, Medicare Claims Hospice Coalition Q & A 2

Processing Manual, Chapter 11. Section 30.3 states, The hospice enters the National Provider Identifier (NPI) and name of the physician currently responsible for certifying the terminal illness, and signing the individual s plan of care for medical care and treatment. 4. If a hospice patient is admitted to a hospital for inpatient hospice and a hospitalist, who is not the attending physician or the medical director for the hospice, sees this patient. Who would the hospitalist bill? Medicare part B, or would the hospice bill for the hospitalist as if they were a consulting physician? In order for physicians to be reimbursed for services provided to a hospice patient, they MUST fall into one of the following categories: Attending Physician NonEmployee: Physician bills Medicare Part B. Attending Physician Employee: Physician bills the hospice and the hospice bills Medicare Part A. Consulting Physician: Physician bills the hospice and the hospice bills Medicare Part A. Any physician services other than those rendered by the attending physician are classified as consulting physician services. The procedure for billing for a consulting physician is the same as that with an employee attending physician as indicated above. The hospice must have a contractual agreement with the consulting physician. Hospice reimbursement to the physician and the time the reimbursement is made are both decisions agreed upon by the hospice and the physician. 5. If an attending physician, who is not a hospice employee, refers a patient to a hospice and continues to provide palliative chemotherapy treatments, in his office, as a part of a physician office visit, can he/she bill Medicare under part B using a GV Modifier? Yes. An attending physician/nurse practitioner that is not employed or contracted by the hospice and is not a hospice volunteer, should bill the Medicare Part B Carrier or A/B MAC using their own Part B provider number. The use of the GV modifier is used if the services are related to the terminal illness. Hospice Coalition Q & A 3

Will he be paid directly for his services including the chemotherapy pharmaceutical? If yes, what is the process? If no, must the hospice contract with the physician and pay the physician for the professional component? Medication components? Entire service? Does Palmetto GBA provide a module on physician billing? The referring physician/ NP should contact their local Part B Carrier or A/B MAC regarding physician billing/services. Palmetto GBA s RHHI does not provide a module on physician billing. Reference: Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) 10002, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services under Hospital Insurance, Section 40.1.3, Physicians' Services. 6. A hospice patient has accessed their Medicaid benefits on admission to hospice. Two months later they become eligible for the Medicare but don t notify the hospice until the following month. Hospice gets a new election benefit statement signed for Medicare and begins to access the Medicare Hospice Benefit after they are notified. Which benefit is responsible for paying the Hospice Benefit for the one month when the patient is knowledgeable of their Medicare benefit but doesn t notify the hospice of such? Our understanding is that the hospice cannot bill retroactively for the Medicare Hospice Benefit without an election statement signed by the beneficiary for the month, yet Medicaid says that Medicare is responsible to pay for that month in question. Hospices are not authorized to bill Medicare for care provided prior to the beneficiary s election of the Medicare Hospice benefit. In cases where a beneficiary s care begins prior to Medicare entitlement, a beneficiary must sign a Medicare Hospice election statement designating the effective date for Medicare hospice care to begin. The election statement cannot retroactively dated. Therefore, any care provided to a beneficiary prior to the date the actual election statement is signed, is not billable to Medicare. If the state Medicaid program requires a denial statement from Medicare, the provider may wish to send a written inquiry to Palmetto GBA requesting a denial statement for the service dates in question. The request should be sent to: Palmetto GBA Medicare Part A, Mail Code: AG620 P. O. Box 100238 Columbia, SC 292023238. As a reminder, providers are responsible for ensuring that they check a patient s Medicare eligibility upon admission and periodically throughout the time in which they are providing care. Hospice Coalition Q & A 4

7. How many adjusted claims is Palmetto GBA receiving from hospices when the adjustment is just to correct the number of visits? Is there an easier way to do this than submitting an adjusted claim? How important is it for a hospice to submit an adjusted claim just to add or subtract one or two visits? Is the visit data being used for anything? This just seems to be a cumbersome process both for Palmetto and for the providers for minimal benefit. Palmetto GBA does not track adjusted claims in order to gather this specific type of data. The visit data, as outlined and explained in CMS Change Request 5567, increases Medicare s ability to ensure optimal payment accuracy in the hospice benefit, and to carefully analyze the services provided in this growing benefit. As a provider of Medicare services, it is the hospice provider s responsibility to provide Medicare with accurate documentation and proper filing of claims, which includes adjustments for services provided. All Medicare providers are subject to audit by various entities in order to ensure optimal payment accuracy within the Medicare systems. 8. Is there any consideration being given to eliminating the requirement for visit reporting (at least for nurses and hospice aides) in an inpatient facility? By its very nature, nursing care in an inpatient setting is a continuous flow 24/7, not a series of independent visits. Consequently, there is no good way to capture this data. And there is no other inpatient setting where Medicare requires nursing visits to be reported. This is requiring a tremendous amount of effort on the part of hospices with inpatient facilities, there is no good way to capture this information accurately, and the data is meaningless. Changes in policy would need to come from CMS. At this time we have no directives to change or eliminate the requirements for visit reporting. Providers should keep in mind that only direct care visits by hospice staff should be reported in an inpatient facility. Visits made by contracted inpatient facility staff members do not need to be reported on the hospice claim. 9. In the Palmetto LCD L6885 (Hospice The Adult Failure to Thrive Syndrome), the following statement is made: In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.2 "abnormal loss of weight" and 799.4 "Cachexia") However, if this advice is followed and ICD9 code 783.2 is billed, Palmetto rejects that code with the explanation that it is not terminal diagnosis. Why does Palmetto recommend using this as an alternate terminal diagnosis and then refuse to accept it for reimbursement? Hospice Coalition Q & A 5

Medical Affairs has corrected the ICD9CM code 783.2, which expanded to the fifth digit last year, to 783.21 within our policy L6885. This has been completed and is on the CMS Web site. This code, 783.2, has been invalid since one year ago. Coders should always verify ICD9CM codes prior to billing. CERTIFICATION 10. I understand that the ANP can be the attending physician but CANNOT certify for terminal illness. What should happen in this scenario: The Advanced Nurse Practitioner is employed by a medical practice that also contracts the Hospice Medical Director. The referral comes as a written order from the hospital, and is often a hospitalist that turns care over to the Hospice. Is the certification of the Medical Director and the original order for hospice from the referring physician enough to meet the initial certification signature criteria? Additionally, there will be the hospital history & physical and relevant eligibility information. Would this be similar to when the Medical Director is also the attending physician and only one signature is required? In this scenario the Medical Director certifies and the ANP serves as the Attending Physician. The attending physician is a doctor of medicine or osteopathy or a nurse practitioner and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual s medical care. When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, who may be a nurse practitioner, not employed by the hospice, in addition to receiving care from hospiceemployed physicians. For the first 90day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group (IDG) and the individual s attending physician. Written certification must be on file in the hospice patient s record prior to submission of a claim to the fiscal intermediary. The initial certification must be signed by the medical director of the hospice or the physician member of the hospice IDG and the individual s attending physician, if the individual has one. If the hospice medical director is also acting as the patient s attending physician, the documentation must be VERY CLEAR that this is the case. A verbal certification must indicate a verbal "certification" and not simply a "verbal order. A statement that simply states "admit to hospice" would not be sufficient when looking for a verbal certification from the physician. Hospice Coalition Q & A 6

11. How will Palmetto GBA review the new physician certification/recertification narratives that will be required beginning October 1, 2009? Will there be any specific content required to avoid a technical denial? Which physician needs to do this (i.e. attending physician or hospice medical director), how long does it need to be, what does it need to contain, etc. Please give some examples. Medical review would expect to see a narrative composed and signed by the physician certifying the beneficiary. The narrative must be specific to the individual beneficiary. It should not contain check boxes or standard language used for all beneficiaries. The narrative should include, under the physician signature, a statement indicating that by signing, the physician confirms that he/she composed the narrative based on his/her review of the beneficiaries medical record or, if applicable, examination of the beneficiary. If the narrative is separate from the actual certification form we would expect to see the physician s signature immediately following the narrative. For the initial certification either the attending physician or the medical director of the hospice may compose the narrative. There is no prescribed length. There are no examples. Each beneficiary would be unique based on their clinical presentation. MEDICAL REVIEW/Additional Development Requests (ADRs) 12. A Medicare patient is to be discharged from a hospice for no longer meeting hospice eligibility and appeals the decision through the QIO, and wins the appeal. The hospice continues to care for the patient. This patient has an ADR for this time period. The hospice receives a denial for this period of time due to the patient not meeting hospice eligibility criteria for the LCD from Palmetto and is denied at the Redetermination and Reconsideration Level. According to the Medicare Claims Processing Manual, Publication 1004, Chapter 1, Section 150.3.2.(B), Intermediary medical review should never repeat or contradict the results of QIO review regarding coverage, since this would be duplicative and QIO decisions are binding, and QIOs are bound by the same coverage policy in making their determinations. In addition, in the Final Rule implementing expedited determination procedures for provider service termination (69 FR 69252, Nov 26, 2004); CMS indicated a QIO s expedited determination constitutes a binding Medicare determination as to whether an individual s provider services are covered. Medicare contractors will be informed of the expedited QIO determinations in all these situations, and contractors payment determinations will reflect the results of the QIO s review Can you explain how these denials continue to occur in these situations? There may be instances when a claim is reviewed by Palmetto GBA prior to receiving the Quality Improvement Organization (QIO) decision. The scope of the QIO determination is limited to the decision to discharge at that point Hospice Coalition Q & A 7

in time. In addition, coverage decisions made Palmetto GBA are based on documentation submitted at the time of the review. Providers may include a copy of the QIO determination with the medical record if the provider determines it may be helpful. 13. Programs are reporting that Palmetto GBA continues to deny patients on ADR submissions stating that the comorbid illness does not meet the LCD criteria for that particular disease. Can you comment on that? As stated in response to previous coalition questions on this topic, Medical Review does not deny claims based on the fact that the beneficiary did not meet criteria established in the LCDs for comorbid conditions listed. All documentation submitted is considered when a medical review determination is made. If documentation of the beneficiary s condition does not meet the criteria for coverage based on the LCD for their primary diagnosis, then all other diagnoses listed in the documentation are reviewed to determine if the claim may be paid based on the other comorbid condition(s). Providers may contact Palmetto GBA with specific review examples if the decision is not understood. 14. Can you provide some clarification as to how information should be submitted to Palmetto GBA regarding ADRs that are requested during a routine patient review for recertification and felt to no longer meet eligibility criteria and is quickly discharged from the hospice? There appears to be no time given for this interdisciplinary group discussion and discharge process, even when following regulations regarding notification of the patient and appropriate prompt discharge planning. Beneficiaries should be discharged as soon as the provider determines they are no longer appropriate for the benefit. Hospice providers should have a detailed discharge planning process in place if it is determined that a beneficiary does not continue to meet the criteria defined by the Medicare hospice benefit. The discharge planning process must take into account the prospect that a beneficiary's condition might stabilize or otherwise change such that the beneficiary cannot continue to be certified as terminally ill. The discharge planning process must also include planning for any necessary family counseling, beneficiary education, or other services before the beneficiary is discharged. This does not mean that each beneficiary will have a discharge plan but that the provider has a process established to address such situations should they arise. Hospice Coalition Q & A 8

15. Can Palmetto GBA provide statistics regarding the overall percent of ADR cases with monetary values that have been won by the appellant at the redetermination, reconsideration and administrative law judge (ALJ) levels over a certain period of time? Has there been given any thought regarding the resources that are required from providers and Medicare regarding this process and what level of denial reversals are acceptable to CMS/Palmetto GBA? In other words, it appears that the first level ADR decisions are reversed in a large number/percent of cases at the redetermination, reconsideration or ALJ level, which requires significant manpower/resources for the provider AND Medicare. What is considered a reasonable overturn rate for ADRs considering these implications? Palmetto GBA is experiencing a fairly high overturn rate at the Administrative Law Judge (ALJ) level but very much aligned with affirmations at the second level of appeal. Based on our observation of the decisions, the ALJs are challenged in differentiating between chronically ill and terminally ill conditions. The ALJs apply different criteria than the intermediaries in many instances and additional information is often provided at the subsequent level contributing to the ALJs decision. Beneficiaries or representatives may attend ALJ hearings, as well. We monitor reversal rates for educational and improvement opportunities but do not have a target rate. 16. Please provide us a report regarding the ALJ cases and hospice reversal rates. Please review the Hospice Reversal Rate by State report (Attachment F) at the end of this document 17. How many hospices are under the new NCLOS probe and how many charts do you intend to request from each before deciding whether to continue the probe? Also, it seems like the NCLOS rate used as the cutoff for this probe is lower (tighter) than the one used on the 2007 probe. What was the cutoff then and what was the cutoff for the current probe? If, indeed, the current one is a lower rate, does this mean that Palmetto GBA is tightening down on what it considers to be an appropriate LOS for noncancer patients? There were 368 providers identified based on the NCLOS rates for July 2008 December 2008 processing period. The established NCLOS rate for this period was.21. Providers with a rate of.23 or greater were selected for review. In 2007 the established NCLOS rate was.19 and the providers with a rate of.21 or greater were selected for review. Reminder on how the NCLOS Rate Calculation is performed NCLOS Rates are calculated using the following formula*: Number of noncancer beneficiaries with LOS >210 Total number of noncancer beneficiaries Hospice Coalition Q & A 9

*NCLOS Rate values can range from 0, no beneficiaries had stays > 210 days; to 1 all had stays > 210 days. The units are per 100 beneficiaries (e.g., a NCLOS Rate of 0.15 means that 15 beneficiaries out of 100 had stays > 210 days) 18. Does Palmetto GBA have any additional probes planned at this time? Palmetto GBA continues to analyze standard data, Hospice CAP information, length of stay (not related to noncancer) and Consolidated Error Rate Testing CERT data. While there are no specific edits in process at this time, this does not mean that additional reviews will not be initiated based on findings. GENERAL 19. Please provide us a CAP report for the most recent period and a trending summary of the past CAP reporting periods, dating back 5 years if possible. 20042007 reports are attached. Please see Attachments AD. 20. Is there additional clarification/direction that Palmetto GBA can provide on such areas of physician contracting and payment? Information regarding physician contracting can be found in the CMS Internet Only Manual (IOM) at www.cms.hhs.gov/manuals, Publication 100 02, Chapter 9, Section 40.3. If the hospice does not have a contract with the physician and the services are provided anyway, is the hospice responsible for payment? The hospice remains the professional manager of the patients care at all times while the patient has elected the Medicare Hospice Benefit. This should be explained to the patient and the family upon admission. Once the Plan of Care is established by the physician and members of the IDG, the hospice is responsible for providing all the services indicated on the plan of care. We encourage providers to work together and establish contracts for services the hospice agency does not provide. If a contract is not established or if the patient seeks out services without pre approval from the hospice then the hospice would not be responsible for charges incurred. If the hospice medical director and the attending physician disagree on what is palliative and or the number of treatments, for example, and the service is provided anyway, is the hospice responsible in the situation where a contract is in place? Hospice Coalition Q & A 10

The hospice remains the professional manager of the patients care. Therefore, the plan of care and all services for that patient should be agreed upon when the plan of care is established. This includes such things as the number of treatments and services provided. 21. I keep hearing that home health and hospice can be providing care and billing on the same patient. Can you provide examples of times when this would be appropriate? It would be rare that a home health agency could provide care unrelated to the terminal illness. For example, the home health agency is ordered to provide care related to injuries resulting from a fall in the home. A determination would have to remove any possibility that the fall was related to the terminal illness. For example, was the fall the result of the effects of pain medication for the pain associated with the terminal illness? Did the patient have bone metastasis resulting in a fracture? Was the fall the result of dementia related to the terminal illness? 22. Automatic crossovers for Medicare patients who have secondary or supplemental private insurance policies are being sent to the private insurance companies after Medicare has either paid or denied payment on a claim. These insurance companies either pay on the additional information (e.g. the visit data required by CR 5567) or send denial EOB's to patients. Can this be turned off? Since there are no copays or deductibles for hospice under Medicare, there is no reason these claims need to be sent to the secondary payers. This is causing great distress among the patients and families because they think they will have to pay if the EOB states the insurance company is not paying. This is also causing problems for providers who have to send back money to these insurance companies because the insurance companieshave paid on the additional data required by CMS. In an effort to reduce confusion, improper secondary payments and unnecessary appeals by beneficiaries, Change Request (CR) 6386, instructs contractors to process charges for revenue discipline codes as covered charges on Remittance Advices (RAs) and Medicare Secondary Notices (MSNs). Palmetto GBA is required to process all claims in accordance with CMS guidelines as outlined in Change Request 5567. Regarding automatic crossovers, the Centers for Medicare & Medicaid Services (CMS) consolidated the Medicare paid claim crossover process through the COB Agreement (COBA) program. Under the automatic crossover process, other supplemental insurers, including Medicaid agencies, sign a standard national Coordination of Benefits Agreement (COBA) with the CMS contractor, the Coordination of Benefits Contractor (COBC). The COBC, in turn, transmits this information to the CMS Common Working File (CWF). After the CMS CWF system tags individual claims for crossover to a designated insurer, it then prompts the Medicare contractor Hospice Coalition Q & A 11

to send the adjudicated claims to the COBC for crossover purposes once the claims have met their payment floor requirements, as prescribed by CMS. Change Request (CR) 6386, issued on April 24, 2009, effective October 1, 2009. CMS Internet Only Manual (IOM) Pub 10004, Medicare Claims Processing Manual Chapter 28 Coordination with Medigap, Medicaid, and Other Complementary Insurers, Section 70.6 Consolidation of the Claims Crossover Process. 23. Hospices continue to have patients/families that are irate over the amount of charges they see on their EOBs as a result of the visit charges CMS is requiring. Sometimes the hospice is able to explain this so the patient/family understands; others become so outraged (thinking that the hospice is overcharging Medicare) that they forget about the wonderful care they received, turn against the hospice, and even threaten to go to the media to expose the scam. This is causing tremendous trouble for hospices. Since this is strictly data that CMS requires and has nothing to do with the beneficiary, can this be turned off so these additional charges don t appear on the patient s EOB? Palmetto GBA is not authorized to make any changes to the beneficiaries Medicare Summary Notices (MSN) unless directed to do so by the Centers for Medicare & Medicaid Services (CMS). Therefore, all information printed on the MSNs is in direct correlation to CMS instructions provided in Change Request (CR) 5567, which was originally issued on February 12, 2008. CR 6386, issued on April 24, 2009, effective October 1, 2009, instructs Medicare contractors to process the charges for the discipline revenue codes as covered charges. This means that the charges will also be displayed on the MSNs in the same manner. 24. A provider is reporting that the Palmetto GBA system is consistently failing to recognize correct addresses. This results in lost letters at every stage of FMR including initial letters, nonreceipt of charts, lost redetermination, and reconsideration notices. Is there anything that can be done to improve the system? Palmetto GBA recognizes the difficulties providers have had with the Additional Development Requests (ADRs) being generated with the appropriate address. This is related to the letter generation process used in the Fiscal Intermediary Shared System (FISS). The FISS Medical Review Address Field is no longer supported by an automated system, which has caused the addressing issues that providers have been experiencing with the ADRs. Palmetto GBA made a request to the FISS Maintainer to modify which field the information is pulled from to generate the letters. This request has been accepted and was implemented with system changes. With this change, the address located in the FISS Other Address Field will be used to generate the ADRs. If that field is blank the Hospice Coalition Q & A 12

Master Address Field will be used. Providers should ensure that they have an accurate 855A on file. 25. Provide us an update on the ARRA stimulus pay back and when Palmetto plans on having those dollars paid to the providers? What will the process be and how will the dollars come to the providers? Palmetto GBA has started this process and it will be completed by October 2009. 26. Please share with us the educational plan for 2010. Palmetto GBA will be having a 2010 Billing and Medical Review Workshop Series. These workshops will be held in conjunction with State Association Conferences as a partnership event once again. Associations interested in obtaining speakers for their 2010 conferences will need to fill out the 2010 RHHI Workshop Request form (Attachment G) and fax it to Krisdee Foster at (803) 9350140. Dates will be filled on a first come first serve basis. Associations will be responsible for obtaining two hotel rooms at the conference hotel for the speakers and allowing a 3.54 hour block of time for the presentation. Palmetto GBA will cover all other travel expenses. Online training will be available in 2010. Medicare Secondary Payer (MSP) classes have been added to this year s schedule. AsktheContractor Teleconferences (ACT) calls will be held quarterly and will be set up differently than in the past. This year providers will be asked to submit any questions on any topic via fax approximately one week prior to the call. Questions will then be addressed on the call by the ombudsmen. A Provider Enrollment Department representative will also participate on each of the ACT calls to answer any provider enrollment issues or concerns. The Provider Outreach and Education Advisory Group (POEAG) will also be held quarterly. We ask state associations to encourage providers that would be interested in serving on the POEAG group to fill out the nomination form located at www.palmettogba.com/rhhi. All other outreach and education events will be posted on the Palmetto GBA Web site at www.palmettogba.com/rhhi under Learning and Education by the end of September 2009. Hospice Coalition Q & A 13

27. Can Dr. Brennan give an update report on the IAC, its members, meeting schedule, upcoming agenda, etc.? The Hospice Intermediary Advisory Committee (IAC) has been formulated and the members notified. The list of primary and alternate members is Attachment H. Our first meeting is a conference call scheduled for tomorrow, September 10, 2009 at 2 p.m. EST. The agenda includes an introduction of all members, update of the A/B MAC decision process as it affects hospice, general discussion of hospice policies (including some expressly requested for discussion Cardiopulmonary, Liver Disease and Renal Care), the possibility of the introduction of a new LCD for 2010, continuing inclusion of the ICF and the ICD10CM into policies, and discussion of planning for a facetoface meeting to be held in the future. 28. There are discrepancies regarding the definitions used for FAST on thelcd for Hospice Alzheimer's Disease and related disorders (L16343). Reisberg who developed the FAST scale defines FAST 7A and 7B as: 7A Ability to speak limited to approximately a half a dozen intelligibledifferent words or fewer, in the course of an average day or in thecourse of an intensive interview. 7B Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over). Palmetto's LCD says: Stage #7: Loss of speech, locomotion, and consciousness: * Substage 7a: Ability to speak limited (1 to 5 words a day) * Substage 7b: All intelligible vocabulary lost Why did Palmetto GBA redefine these parameters on a previously validated and widely used tool? Palmetto GBA did not redefine these stages. The descriptions included in the LCD are abbreviated, yet convey the necessary understanding of Stages 7a and 7b. Our verbiage was not intended to replace the actual language used by Dr. Reisberg. A physician who applies the FAST scale to patient characteristics for purposes of determining prognosis should utilize Dr. Reisberg s actual reference. This scale is intended to allow health care professionals chart the decline of people with Alzheimer s disease. Hospice Coalition Q & A 14

The original article accompanying the release of LCD L16343, published April 28, 2004, stated: Palmetto GBA has reviewed comments submitted in response to the proposed Local Coverage Determination (LCD) Hospice Alzheimer s Disease & Related Disorders. The most frequent comment addressed the use the Functional Assessment Staging Scale (FAST) level 7c, as the level of activity limitation that would support a prognosis of sixmonths or less. Several comments included requests that FAST stage 7 or above be used as the level of activity limitation that, together with comorbid or secondary conditions, would support a terminal prognosis. Based on these comments Palmetto GBA has changed FAST stage 7c to FAST stage 7 or above. This is the reasoning behind the inclusion of stage 7 or above and why stages 7a and 7b were not prescribed. There remains in the literature the concern that the FAST scale cannot be applied alone to determine prognosis for individuals with dementia, in particular nonalzheimer s dementia. This particular LCD only addresses Alzheimer s disease. The greater question is whether it is unrealistic to predict six month terminality in a reasonably accurate manner. This LCD emphasizes the necessity of describing relevant comorbid or secondary conditions and their impact upon the primary diagnosis for hospice (here, Alzheimer s disease) when establishing a plan of care in order to address the unique characteristics of each beneficiary. The content of this LCD is not meant to replace ongoing scientific, evidence based literature that might establish adequate predictive guidelines for identification of six months survival in patients suffering from Alzheimer s disease. This LCD is also intended to provide guidance on the proper development of interventional strategies which must be documented in order to determine reasonable and necessary Medicare Hospice Services. The difficulty with determining prognosis in persons with Alzheimer s disease should not stand as a barrier for allowing patients access to hospice benefits. Our newly formed Hospice Intermediary Advisory Committee may be able to address this particular LCD and investigate what recent literature offers in the way of reliable predictive criteria for this patient type. Hospice Coalition Q & A 15

ATTACHMENT A Palmetto GBA 2004 Hospice Cap Overpayments by State Item State Total O/P Number Code State Providers With O/P % Amount 1 1 Alabama 78 31 40% $ 23,755,948.00 2 3 Arizona 4 2 50% $ 1,664,438.00 3 4 Arkansas 16 1 6% $ 116,519.00 4 5 California 9 0 N/A $ 5 6 Colorada 1 0 N/A $ 6 8 Delaware 1 0 N/A $ 7 10 Florida 38 1 3% $ 244,439.00 8 11 Georgia 66 5 8% $ 4,448,279.00 9 14 Illinois 52 2 4% $ 236,674.00 10 15 Indiana 40 5 12% $ 1,210,870.00 11 16 Iowa 1 0 N/A $ 12 17 Kansas 1 1 100% $ 827,432.00 13 18 Kentucky 17 0 N/A $ 14 19 Louisiana 45 1 2% $ 199,928.00 15 22 Massachusetts 3 0 N/A $ 16 24 Minnesota 1 0 N/A $ 17 25 Mississippi 53 26 45% $ 26,094,120.00 18 26 Missouri 3 0 N/A $ 19 28 Nebraska 2 0 N/A $ 20 29 Nevada 1 0 N/A $ 21 31 New Jersey 4 0 N/A $ 22 32 New Mexico 24 7 29% $ 5,421,743.00 23 33 New York 1 0 N/A $ 24 34 North Carolina 62 4 6% $ 7,706,289.00 25 36 Ohio 57 0 N/A $ 26 37 Oklahoma 73 17 23% $ 14,504,714.00 27 39 Pennsylvania 6 0 N/A $ 28 42 South Carolina 37 2 5% $ 750,048.00 29 44 Tennessee 31 1 3% $ 3,149.00 30 45 Texas 125 6 5 $ 1,509,588.00 31 46 Utah 2 2 100% $ 4,129,651.00 32 49 Virginia 6 0 N/A $ 33 52 Wisconsin 2 0 N/A $ TOTAL 862 114 $ 92,823,829.00

ATTACHMENT B Palmettop GBA 2005 Hospice Cap Overpayments by State Item State Total Providers O/P Number Code State Providers With O/P % Amount 1 1 Alabama 90 42 47% (37,117,328.00) 2 3 Arizona 5 4 80% (11,775,070.00) 3 4 Arkansas 19 2 11% (441,594.00) 4 5 California 10 0 0% 0.00 5 6 Colorada 1 0 0% 0.00 6 8 Delaware 1 0 0% 0.00 7 10 Florida 36 3 8% (1,391,572.00) 8 11 Georgia 70 12 17% (8,022,922.00) 9 14 Illinois 49 3 6% (2,337,608.00) 10 15 Indiana 42 7 17% (2,324,609.00) 11 16 Iowa 1 0 0% 0.00 12 17 Kansas 1 1 100% (1,086,598.00) 13 18 Kentucky 17 0 0% 0.00 14 19 Louisiana 62 3 5% (1,323,543.00) 15 22 Massachusetts 4 0 0% 0.00 16 23 Michigan 2 0 0% 0.00 16 24 Minnesota 1 0 0% 0.00 17 25 Mississippi 60 38 63% (45,327,974.00) 18 26 Missouri 9 0 0% 0.00 19 28 Nebraska 2 0 0% 0.00 20 29 Nevada 1 0 0% 0.00 21 31 New Jersey 5 0 0% 0.00 22 32 New Mexico 27 10 37% (3,589,744.00) 23 33 New York 1 0 0% 0.00 24 34 North Carolina 64 4 6% (11,351,232.00) 25 36 Ohio 60 1 2% (132,376.00) 26 37 Oklahoma 99 41 41% (25,112,067.00) 27 39 Pennsylvania 10 0 0% 0.00 28 42 South Carolina 42 5 12% (1,342,803.00) 29 44 Tennessee 35 1 3% (98,201.00) 30 45 Texas 147 7 5% (3,787,767.00) 31 46 Utah 2 1 50% (2,809,247.00) 32 49 Virginia 6 0 0% 0.00 33 52 Wisconsin 3 0 0% 0.00 984 185 (159,372,255.00) x

ATTACHMENT C Palmetto GBA 2006 Hospice Cap Overpayments by State AS OF 12/18/08 Item State Total % completed # of Providers O/P # Code State Providers Completed With O/P with O/P First o/p in 2006 Amount 1 1 Alabama 91 91 44 48% 9 ($47,972,054) 2 3 Arizona 7 7 4 57% 0 ($18,148,212) 3 4 Arkansas 25 25 1 4% 1 ($473,812) 4 5 California 12 12 0 0% 5 6 Colorada 1 1 0 0% 6 7 New Jersey 2 2 0 0% 7 8 Delaware 2 2 0 0% 8 10 Florida 38 38 4 11% 2 ($4,259,877) 9 11 Georgia 78 78 12 15% 7 ($6,698,003) 10 14 Illinois 56 56 5 9% 2 ($913,645) 11 15 Indiana 46 46 7 15% 3 ($2,121,481) 12 16 Iowa 1 1 0 0% 13 17 Kansas 1 1 1 100% 0 ($815,797) 14 18 Kentucky 18 18 0 0% 15 19 Louisiana 81 81 9 11% 6 ($2,478,962) 16 22 Massachusetts 6 6 0 0% 17 23 Michigan 3 3 0 0% 18 24 Minnesota 2 2 0 0% 19 25 Mississippi 85 85 47 55% 12 ($46,489,805) 20 26 Missouri 9 9 1 11% 1 ($83,287) 21 28 Nebraska 3 3 0 0% 22 29 Nevada 1 1 0 0% 23 31 New Jersey 5 5 1 20% 1 ($260,168) 24 32 New Mexico 33 33 9 27% 1 ($5,987,706) 25 33 New York 1 1 0 0% 26 34 North Carolina 64 64 7 11% 4 ($15,042,454) 27 36 Ohio 66 66 2 3% 2 ($1,680,878) 28 37 Oklahoma 112 112 47 42% 15 ($28,080,157) 29 39 Pennsylvania 12 12 0 0% 30 42 South Carolina 47 47 8 17% 5 ($3,400,385) 31 44 Tennessee 43 43 1 2% 0 ($390,985) 32 45 Texas 189 189 19 10% 13 ($8,987,598) 33 46 Utah 2 2 1 50% 0 ($147,086) 34 49 Virginia 10 10 0 0% 35 51 West Virginia 1 1 0 0% 36 52 Wisconsin 2 2 0 0% TOTAL 1,155 1,155 230 20% 84 ($194,432,352) TOTAL for 2005 Cap Year 984 984 185 19% ($159,372,255)

ATTACHMENT D Palmetto GBA 2007 Hospice Cap Overpayments by State AS OF 09/1/09 Item State Total % completed Total O/P Average O/P # Code State Providers Completed With O/P with O/P Amount Amount 1 1 Alabama 100 100 40 40% ($38,208,971) ($955,224) 2 3 Arizona 8 8 4 50% ($7,790,268) ($1,947,567) 3 4 Arkansas 27 27 1 4% ($16,383) ($16,383) 4 5 California 12 12 1 8% ($133,472) ($133,472) 5 6 Colorada 1 1 0 0% 6 7 Connecticut 2 2 0 0% 7 8 Delaware 2 2 0 0% 8 9 Washington DC 1 1 0 0% 9 10 Florida 39 39 1 3% ($5,727,380) ($5,727,380) 10 11 Georgia 82 81 17 21% ($5,377,836) ($316,343) 11 14 Illinois 58 58 3 5% ($2,186,350) ($728,783) 12 15 Indiana 49 49 3 6% ($691,560) ($230,520) 13 16 Iowa 1 1 0 0% 14 17 Kansas 3 3 1 33% ($741,055) ($741,055) 15 18 Kentucky 17 17 0 0% 16 19 Louisiana 93 93 15 16% ($3,455,702) ($230,380) 17 22 Massachusetts 4 4 0 0% 18 23 Michigan 3 3 0 0% 19 24 Minnesota 2 2 0 0% 20 25 Mississippi 97 97 57 59% ($44,273,133) ($776,722) 21 26 Missouri 12 12 0 0% 22 28 Nebraska 3 3 0 0% 23 29 Nevada 1 1 0 0% 24 31 New Jersey 4 4 0 0% 25 32 New Mexico 28 28 4 14% ($2,020,514) ($505,129) 26 33 New York 1 1 0 0% 27 34 North Carolina 64 64 7 11% ($12,695,648) ($1,813,664) 28 36 Ohio 69 69 4 6% ($2,471,565) ($617,891) 29 37 Oklahoma 113 113 45 40% ($30,686,437) ($681,921) 30 39 Pennsylvania 13 13 3 23% ($406,426) ($135,475) 31 42 South Carolina 56 56 15 27% ($7,258,655) ($483,910) 32 44 Tennessee 47 47 1 2% ($186,053) ($186,053) 33 45 Texas 225 225 25 11% ($10,240,816) ($409,633) 34 46 Utah 2 2 0 0% 35 49 Virginia 13 13 0 0% 36 51 West Virginia 1 1 0 0% 37 52 Wisconsin 3 3 1 33% ($95,054) ($95,054) TOTAL 1,256 1,255 248 20% ($174,663,278) ($704,287) TOTAL for 2006 Cap Year 1155 1155 230 20% ($194,432,352) ($845,358)