Crossroads for Hospice

Hospices are under intense pressure from numerous federal rules and regulations.  Medicare reimbursement for Hospices is not keeping up with inflation. CMS is targeting hospices that have a high percentage of long length of stay patients.  Several of the Medicare Administrative Contractors (MACs) have initiated special audit steps to review hospice claims that have high length of stay to ensure they have the proper documentation and were good candidates for hospice when they were admitted.

Many hospices have been audited by Zone Program Integrity Contractors (ZPICs) and Recovery (RACs) for various claim issues. Always remember that ZPICs and RACs are bounty hunters.  They get paid for what they deny.  In my opinion auditors should not be paid bounties.  This creates a need to find problems whether they exist or not.  A very large percentage of these denials are overturned when they are taken through the appeal process.  Unfortunately many hospices do not have the funds or the expertise to complete the appeals process.

CMS in the proposed hospice rules and rates for 2014 have really hit the diagnosis issue hard.  They have removed adult failure to thrive and debility as primary hospice diagnosis, even though these were both in the top 5 hospice diagnosis last year.  There is no waiting period for this rule.  CMS stated that this was simply a clarification of existing rules.  They will allow adult failure to thrive and debility as secondary diagnosis.  CMS reported that most hospice claims had only one diagnosis.  They want hospices to include all secondary diagnosis related to the terminal condition.  This is a large change and will require intense staff training.

Hospices have to comply with the revised HIPAA rules.  Failure to comply can lead the excessive fines and penalties.  The Healthcare Reform Bill will eventually cost hospices cash and will require additional administration expense.  There are also fines for hospices that fail to comply.  Have you noticed all of the various fines and penalties?  This appears to be a new found revenue source for Medicare and other government programs.

Hospices are at a crossroads.  They must either learn to comply with the new rules and regulations or they will be forced out of business.  Successful hospices will know the rules, regulations, and will implement plans to ensure they are complying.

We are having an excellent seminar on September 18 to 20 that will discuss all of the above issues and much more.  It will be held at the Hilton Waikoloa Village on the Big Island of Hawaii.  The room block will be released on August 15.  Make your reservations prior to that date.

Crisis in Home Health

Home health agencies are under intense pressure from numerous federal rules and regulations.  Actual Medicare episode reimbursement has increased less than 2% since home Heath began PPS in 2000, while inflation for the same period has increased over 35%.  The face-to-face encounter rules have caused friction between the referring physicians and home health agencies. Most if not all of the education regarding the face-to-face encounters has been left to the home health agencies and their staff.  Several of the Medicare Administrative Contractors (MACs) have initiated special audit steps to review home health claims to ensure the home health agencies have the proper documentation.  They claim there is a high level of non-compliance to the face-to-face encounter documentation.  CMS is even planning to educate the physicians this fall.  That is like closing the barn door after the horses have escaped.

Many home health agencies have been audited by Zone Program Integrity Contractors (ZPICs) and Recovery (RACs) for various claim issues. Always remember that ZPICs and RACs are bounty hunters.  They get paid for what they deny.  In my opinion auditors should not be paid bounties.  This creates a need to find problems whether they exist or not.  A very large percentage of these denials are overturned when they are taken through the appeal process.  Unfortunately many home health agencies do not have the funds or the expertise to complete the appeals process.

There are proposed cuts in home health reimbursement again this year.  They have also proposed additional cuts for 2015, 2016, and 2017.  They are proposing to remove 170 codes from obtaining points in the HIPPA Grouper software.  The impact of removing these codes will impact every home health agency differently bases on the makeup of their patients.

Home health has to comply with revised HIPAA rules.  Failure to comply can lead the excessive fines and penalties.  Home health survey deficiencies could lead to fines, penalties, and removal from Medicare program.   The Healthcare Reform Bill will eventually cost home health agencies cash and will require additional administration expense.  There are also fines for home health agencies that fail to comply.  Have you noticed all of the various fines and penalties?  This appears to be a new found revenue source for Medicare and other government programs.

Home Health Agencies are at a crossroads.  They must either learn to comply with the new rules, regulations, and reduced payment rates or they will be forced out of business.  Successful home health agencies will know the rules, regulations, and will implement plans to ensure they are complying.

We are having an excellent seminar on September 23 to 25 that will discuss all of the above issues and much more.  It will be held at the Hilton Waikoloa Village on the Big Island of Hawaii.  The room block will be released on August 15, be sure to make your reservations before that date.

Hospice Claim Submission Guide

NHIC, Corp a Medicare Administrative Contractor (MAC) issued a twenty two page hospice claim submission guide.  This guide provides complete field by field instructions for hospice billing.  This is a valuable resource for all hospice employees who bill Medicare regardless of which (MAC) serves your hospice.

You can download the guide by using the following link:

http://www.medicarenhic.com/providers/pubs/HospiceClaimBG.pdf

Temporary Moratorium

CMS Administrator issued a Temporary Moratorium to prohibit enrollment of new home health agencies in Miami-Dade County, Florida and surrounding counties and Cook County, IL and surrounding counties.  They have also issued a Temporary Moratorium to prohibit enrollment of new ambulance providers in Harris County, TX and surrounding counties.  This authority was granted as part of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010.  These are also known as the Affordable Care Act.  This moratorium applies to the Medicare Program, the Medicaid Program, and the Children’s Health Insurance Program. 

A final rule was published in the Federal Register on February 2, 2011 titled “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspension and Compliance Plans for Providers and Suppliers. The final rule states CMS may impose a temporary moratorium on newly enrolling Medicare Providers and Suppliers if they  determine that there is a significant potential for fraud, waste, or abuses with a particular provider or supplier type or particular geographic areas or both.  The Moratorium is for a six month period, but may be extended beyond for additional six month periods if CMS determines it needs to remain in place.

The moratorium for new home health agency enrollment applies to Miami-Dade County and Monroe County in Florida.  The moratorium for new home health enrollment applies to Cook, DuPage, Kane, Lake, McHenry, and Will Counties in Illinois.  The moratorium for new ambulance suppliers in Harris, Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller counties in Texas.

For more information please use the following temporary link:

http://www.ofr.gov/(S(ga215hcckaqho1kou2yohgph))/OFRUpload/OFRData/2013-18394_PI.pdf

Success with ADRs

All of us feel bombarded by Additional Document Requests (ADR) for our Medicare Administrative Contractors (MACs) or other Medical Record Request from other program reviewers.  CGS which is the MAC for 15 states has developed a new tool to help providers succeed with Medicare Records Request.  They have come up with an acronym that spells success.  Their key words are Success, Understand, Contact, Coordinate, Expect, Submit, and Send (SUCCESS).

This would be a great tool for all home health agencies and hospices to utilize to help them respond to ADRs and other medical record request.  It actually gives you the Program that is requesting the documents (CERT, ADR, RA, or ZPIC) and the timeline to submit records.  Some of the addresses are incorrect if you are not served by the CGS MAC, but this report gives you great information.

For more information please uses the following link:

http://www.cgsmedicare.com/hhh/education/materials/pdf/Success_MR_Requests.pdf

Some Pioneer ACOs Exit Program

CMS issued a press release on July 16, 2013 detailing results from the Pioneer Accountable Care Organizations.  The report showed positive results for some of the Pioneer ACO’s who both higher quality care and lower Medicare expenditures.  Made possible by the Affordable Care Act, the Pioneer ACO Model encourages providers and caregivers to deliver more coordinated care for Medicare beneficiaries. This model, launched by the CMS Innovation Center, is part of the Affordable Care Act’s efforts to realign payment incentives, promoting high quality, efficient care for Medicare beneficiaries.  ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely.  

The news was not all positive.  7 Pioneer ACOs that did not produce savings have notified CMS that they intend to apply to the Medicare Shared Savings Program – another ACO model.  2 Pioneer ACOs have indicated to CMS their intent to leave the program.  Overall, more than 250 organizations participate in the Pioneer ACO Model and the Medicare Shared Savings Program, serving 4 million Medicare beneficiaries, and more ACOs can join the Shared Savings Program each January.

For more information please uses the following link:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

11 States Limited Home Health Access

The Office of Inspector General issued a letter to CMS concerning States that improperly restrict eligibility for Medicaid Mandatory Home Health Services.  In July of 2000, CMS released a State Medical Director letter summarizing it efforts to review Federal policies to ensure fulfillment of the Americans with Disabilities Act.  The letter stated that, although Medicare requires beneficiaries to be homebound to qualify for home health services, imposing a homebound requirement on Medicaid home health benefits violates Medicaid regulations related to “amount, duration, and scope of services.  In July of 2011, CMS published a Notice of Proposed Rulemaking that would review Medicaid regulations to clarify that home health services cannot be restricted to individuals who are homebound or to services furnish in the home.  This rule has not been published in final form as of this date. The eleven states that the OIG listed as violating parts of this requirement are Alabama, Arkansas, Indiana, Montana, Nebraska, New Mexico, North Dakota, Pennsylvania, South Dakota, Utah, and West Virginia.

For more information please utilize the link below:

http://oig.hhs.gov/oei/reports/oei-07-13-00060.pdf