Transcript July 1, 2014 - Nebraska Hospice and Palliative Care Association

Regulations:
A Year in Review and
A Look to the Future
Outline
• Nebraska Hospice
Landscape
• State Licensure and
Regulations
• Survey Deficiencies
• Hospice Wage Index
• Quality Reporting
• Proposed Rulemaking
• Change Requests
• Provider Bulletins
• Hospice Scrutiny
–
–
–
–
OIG
MEDPAC
RAC
PEPPER
• Fiscal Intermediary
Information
• Resources
8277
Nebraska Hospice Admissions
2002-2012
5192
4160
2002
4472
2003
5511
7747
7172
6529
6603
2008
2009
5811
4735
2004
2005
2006
2007
2010
2011
2012
2012 Demographics & Hospice Utilization
Nebraska
National
Population
1,855,525
313,878,238
Total Deaths
15,022
2,512,991
Medicare Beneficiaries Deaths
12,721
2,022,574
Medicare Hospice Beneficiary Admissions
7,847
62% of Medicare deaths
1,257,735
62% of Medicare deaths
Medicare Hospice Beneficiary Deaths
Medicare Hospice Total Days of Care
5,953
46.8% of Medicare
deaths
468,804 days
897,379
44.4% of Medicare
deaths
89,817,308 days
Medicare Hospice Mean Days/Beneficiary
Medicare Hospice Median Days/Beneficiary
60 days
21 days
71 days
25 days
Medicare Hospice Discharged Alive
12%
18%
Medicare Hospice Total Payments
$71,282,532
Medicare Hospice Mean Payment/Beneficiary $9,084
$14,882,743,292
$11,842
2012 Medicare Hospice Beneficiaries
Location of Care (days)
All Other Settings
1%
Inpatient Hospice
1%
Assisted Living Facility
Compare:
National
Skilled/Non-Skilled Nursing Facility
17%
Home
24%
57%
1%
1%
Compare:
Nebraska
14%
57%
28%
0%
20%
40%
60%
2012 Medicare Hospice Beneficiaries
Levels of Care (days)
0.1%
100.0%
0.1%
0.4%
0.3%
0.8%
99.0%
1.9%
98.0%
98.9%
97.0%
97.5%
96.0%
Compare: Nebraska
Compare: National
Cont. Home Care
Respite Care
General Inpt
Routine Home Care
2012 Length of Stay
29%
26%
Nebraska
21%
7 days or less
8-29 days
12%
30-89 days
90-179 days
9%
0%
180+ days
20%
40%
State of Nebraska
Nebraska Department of Health
and Human Services
Medicaid Physical Health Managed Care
• RFP to be released this summer and will be
effective July 1, 2015 – will add hospice
and certain other services
• Medicaid hospice services for persons in
nursing facilities or receiving Aged and
Disabled Waiver assisted living services
will continue to be excluded
Nebraska Department of Health
and Human Services
Managed Long Term Services and Support
(MLTSS)
• Medicaid MLTSS RFP will not be released
prior to September 1, 2015 and will not go
live prior to January 1, 2017
Nebraska Department of Health
and Human Services
• Pamela Kerns, RN, Administrator
[email protected]
402-471-3651
• Hospice-specific Web page
http://dhhs.ne.gov/publichealth/Pages/crl_h
cddlabs_hospice_hospice.aspx
Nebraska Hospice Licensure
Title 175, Chapter 16
Effective May 1, 2010
http://www.sos.state.ne.us/rules-andregs/regsearch/Rules/Health_and_Human_S
ervices_System/Title-175/Chapter-16.pdf
State Operational Manual (SOM)
Updated – March 7, 2014
All Chapters:
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-OnlyManuals-IOMs-Items/CMS1201984.html
Appendix M – Hospice
http://cms.hhs.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107a
p_m_hospice.pdf
CMS CY2013
Survey Deficiency Data
• 3,970 Active hospice providers
• 1,301 recertification surveys
• 33% of active providers surveyed
CMS CY2013 Survey Deficiency Data
• L0543 – Plan of Care
– POC not individualized; missing or incomplete
documentation; lack of IDT collaboration; lack
of evidence of patient/family collaboration of
POC goals
• L0545 – Content of Plan of Care
– Missing or inaccurate documentation; physician
orders missing
CMS CY2013 Survey Deficiency Data
• L0530 – Content of Comprehensive
Assessment
– Incomplete medication profiles; lack of updated
medication profiles in patient’s home
• L0555 – Coordination of Services
– Services provided by IDT that were not on
POC and interventions on POC that were not
provided
CMS CY2013 Survey Deficiency Data
• L0547 Content of Plan of Care
– POC contained services missing frequency of
care to be provided
• L0591 – Nursing Services
– Hospice aides performing tasks outside of
scope of practice; RN on-call issues; delays in
RN visits; RN unable to visit frequency for pt
needs
CMS CY2013 Survey Deficiency Data
• L0629 – Supervision of Hospice Aides
– Supervision of hospice aides varied from 16
days to more than 30 days
• L0557 – Coordination of Services
– RN documented at assessment patient declined
chaplain as involved with community church –
chaplain documented repeated messages to
schedule a visit; Patient had private duty aide
services – no documentation to show
coordination of care with private agency
CMS CY2013 Survey Deficiency Data
• L0533 – Update of Comprehensive
Assessment
– RN performed dyspnea assessment but did not
communicate change in status to IDT – other
members of IDT did not take into consideration
when updating the POC
• L0671 – Clinical Records
– Lacked patient signature forms, IDT notes
including aide, volunteer, and chaplain
Patient Protection and
Affordable Care Act
(PPACA)
Hospice Payment Reform
• Will occur no earlier than Oct. 1, 2013, or
FY2014
• Revise methodology for RHC
• Not required to change payment for other
levels of care
Hospice Payment Reform
Medicare Hospice Payment Reform: Hospice Study
Technical Report, April 24, 2013
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/Hospice/Downloads/Hospice-Study-TechnicalReport-4-29-13.pdf
Medicare Hospice Payment Reform: Analyses to Support
Payment Reform, Abt Associates, May 1, 2014
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/Hospice/Downloads/May-2014AnalysesToSupportPaymentReform.pdf
Medicare Care Choices Model
• Initiative to test new payment and service delivery
model
• Beneficiary to receive palliative care services from
certain hospices while concurrently receiving
curative services
http://innovation.cms.gov/initiatives/Medicare-CareChoices/
http://innovation.cms.gov/initiatives/Medicare-CareChoices/faq.html
Hospice Wage Index
FY2014 Medicare Wage Index
CBSA State County Name FY2014 FY2014
FY2014
FY2014 FY2014
Code County
Wage Routine Continuous
Inpt
General
Code
Index
Home Home Care Respite
Inpt
Care
NE
28
NE
2000
84 Other
Counties
0.8894
0.8937
144.20
147.55
841.57
861.15
151.76
155.18
645.04
659.89
30700 28540
Lancaster and
Seward
0.9906
0.9553
155.05
154.29
904.90
900.47
160.60
160.67
690.01
687.81
NE
36540 28270
Cass,
Douglas,
Sarpy,
Saunders, and
Washington
1.0222
0.9847
158.44
157.51
924.67
919.23
163.36
163.29
704.05
701.14
NE
43580 28210
Dakota and
Dixon
0.9176
0.9248
147.22
150.96
859.21
881.00
154.22
157.95
657.58
673.99
*Red amount indicates proposed FY2015 rates
as published in Proposed Rule May 2, 2014
Budget Control Act of 2011
“Sequestration”
Sequestration Order issued March 1, 2013
• Medicare Fee-for-Service claims with
dates-of-service or dates-of-discharge on or
after April 1, 2013, will incur a 2 percent
reduction in Medicare payment.
https://www.cgsmedicare.com/parta/pubs/new
s/2013/0313/1005.html
CMS FY2015
Hospice Wage Index
Proposed Rule
May 2, 2014
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/Hospice/Hospice-Regulations-and-NoticesItems/CMS-1609-P.html
Key Elements in FY2015 Proposed Rule
•
•
•
•
•
Data analysis for consideration in hospice payment reform
No hospice payment reform proposed for FY2015
Changes Proposed
– Time frames for Notice of Election (NOE) and new Notice of
Termination/Revocation
– Attending physician is patient decision
– Cap self report and overpayment expected 5 months after close of cap year
– Hospice quality reporting updates
– ICD-9 to ICD-10 Update
Payment Update
– 2% payment update (net 1.3%) for FY2015
– Sequestration means NO payment update for FY2015
Comments Requested
– Definitions of “terminal illness” and “related conditions”
– Part D and hospice communication
Analyses for Payment Reform
1. No skilled visits in last 48 hours of life
2. Analysis of GIP, Continuous Home Care and
Inpatient Respite
3. Live discharges
a.
b.
Frequency of live discharges
Live discharges and readmissions after hospital stay
4. Medicare expenditures in Part A and B outside the
MHB
5. Medicare expenditures in Part D when patient has
elected hospice
% of Patients with No Skilled Visits
Days before
Death
% of Patients
Last day of life
28.9% of patients
Last 2 days of
life
14.4% of patients
Last 3 days of
life
9.1% of patients
Last 4 days of
life
6.2% of patients
Skilled visits include nurse, social worker, therapies
Lowest % of Patients with No Visits in Last 2
Days of Life
State
% with No
Visits
WI
5.7%
ND
7.3%
VT
7.5%
TN
7.5%
KS
8.5%
Highest % of Patients with No Visits in Last 2
Days of Life
State
% with No
Visits
NJ
23%
MA
22.9%
OR
21.2%
WA
21%
MN
19.4%
Percentage of days by level of care
Level of Care
Percentage of
Total Days
Routine Home Care
97.4%
Continuous Home Care
0.4%
Inpatient Respite Care
0.3%
General Inpatient Care
1.9%
GIP Utilization
• Patient utilization:
77.3% of patients electing hospice did not
have a GIP stay during their hospice election
• Hospices providing GIP
21.1% of hospices did not bill for a single
day of GIP in CY2012
GIP Utilization
Number
Any GIP
of
Provided? Hospices
No
969
Yes
2,758
• National average =
1.9% of days are GIP
• Provide GIP
– 5-10% = 195
hospices
– 10% or more = 46
hospices
Location of GIP
0.8
0.7
68.0%
0.6
0.5
Hospice Inpt Facility
Hospital
Skilled Nursing Facility
Multi
0.4
0.3
24.9%
0.2
0.1
5.5%
1.6%
0
% of Total
Length of GIP Stay by Location
7
6
5
6.1
5.5
4.5
4.7
All
Inpatient Hospice
Inpatient Hospital
SNF
4
3
2
1
0
Average Length of Stay in Days
Continuous Home Care Data
Hospice Characteristic
Billing Continuous
Home Care
Hospices that billed
Continuous Home Care
4 hospices
42% of hospices billed at
least one day of CHC
billed more than 10% of
their days as CHC
40 hospices
accounted for 46% of all
CHC days
> 25% of all CHC days
1 hospice
9.4% of hospices
> 50% provided to patients
in nursing homes
Inpatient Respite Utilization
• Patient Utilization
3.4% in CY2012 used at least 1 day
• Hospices providing Inpatient Respite
26% of hospices did not bill for a single
day of IRC during CY2012
Ongoing Monitoring and Review
• CMS states ongoing monitoring of GIP, CHC,
and IRC utilization
• Review will include:
– Identify hospices with aberrant utilization patterns
– Identify hospices that may be in violation of the CoPs
or payment regulations
• Hospices identified will be referred to
• Survey and Certification
• Office of Financial Management
• Center for Program Integrity
for further investigation
Live Discharges
Year
% of Live Discharges
2000
13.2%
2012
18.1%
July 1 2012
Revocations separated from
hospice-initiated live
discharges
2013 data
Revocations
39%
No longer terminally ill
58%
Rates of Live Discharges
% of Patients
Discharged
Alive
Number of
Hospices
0 – 9.9%
1,601
10% - 19.9%
1,315
20% - 29.9%
371
30% - 39.9%
133
40% +
282
2010 Live Discharge
rates by state
• CT
12.8%
• MS
40.5%
Hospice claims data from CY 2010-CY 2012 for beneficiaries
who were discharged (alive or deceased) in CY 2012
100% Live Discharge Rate
• 71 hospices in CY2012
– Average length of stay: 193 days
– National average lifetime LOS: 95.4 days
• CMS states: We have shared this
information with the Office of Financial
Management and with the Center for
Program Integrity for their review and
follow-up.
Live Discharge and Readmissions
Hospice
Discharge
Hospital
Admission
Expensive
test/procedure
$126 M
2010 Data
13,770 patients of
182,172 live
discharges – 7.5%
Hospice
Readmission
Hospital
Discharge
Live Discharge and Readmission by State
MS
VA
OK
TX
AL
NJ
SC
GA
MD
LA
Medicare A and B Outside Hospice Benefit
Part A or B Service
Percentage of $$ Spent
DME
7.1%
Inpatient care
28.6%
Outpatient Part B services
16.9%
Other Part B services (physician,
practitioner, labs and diagnostic tests,
ambulance transports, and physician
office visits)
Skilled Nursing Facility Care
37.4%
Home Health Care
4.5%
5.7%
States where Medicare A and B Outside
the Hospice Benefit is Highest
WV
FL
TX
MS
SC
Part D Expenditures During a Hospice Stay
• CY2012
– Total Part D spending: $417.9 million
– Paid by Medicare: $334.9 million
• All drug types
• Paid by:
–
–
–
–
Medicare
States
Beneficiaries
Other payers
Highest Part D Expenditures by State
ID
WV
AL
OK
CY2012 Total Non-Hospice
Medicare Spending
For beneficiaries after hospice election
• Parts A & B: $710.1 million
• Part D: $334.9
• TOTAL: $1.3 Billion dollars
Note: 51.6 % of $1.3 billion -- 373 hospices
• Average total per beneficiary: $1,289 in nonhospice costs
PROVISIONS OF PROPOSED
RULE
Notice of Election
• File the Notice of Election with MAC
within 3 calendar days after effective date
of election
• Failure to submit:
Medicare will not cover and pay for days of hospice
care from the effective date of election to the date of
filing of the NOE. Provider may not bill beneficiary.
NOE Filing
• File Notice of Election (NOE) as soon as
possible after the election occurs
• If filed ASAP:
– Limits ability of other Part A, B and D
providers to bill in error
– Provides up to date information on face-to-face
encounter
– Identify current benefit period
– Provide smooth transitions for sequential
billing
Attending Physician
• The attending physician has been identified by the
patient and was his or her choice
• NEW: File a change of attending physician form
with the hospice that states that the patient is
changing his or her attending physician
Notice of Termination
• Filing a Notice of Termination of Election
– When hospice election is ended due to
discharge, the hospice must file a notice of
termination/revocation of election within 3
calendar days after the effective date of the
discharge, unless it has already filed a final
claim for that beneficiary.
Notice of Revocation
• Filing a Notice of Revocation of Election.
– When the hospice election is ended due to
revocation, the hospice must file a notice of
termination/revocation of election with its
Medicare within 3 calendar days after the
effective date of the revocation, unless it has
already filed a final claim for that beneficiary
Payment Penalty for No Quality Reporting
• For FY 2014 and subsequent fiscal years
– if the hospice does not submit hospice quality data,
payment rates are equal to the rates for the previous
fiscal year increased by the applicable market basket
percentage increase, minus 2 percentage points.
– Applies only to the fiscal year involved
– Will not be taken into account in computing the
payment amounts for a subsequent fiscal year.
New Cap Reporting
• File its cap determination notice with its Medicare
contractor
• No later than 5 months after the end of the cap
year (that is, by March 31st)
• Remit any overpayment due at that time.
• If a provider fails to file, payments to the hospice
would be suspended in whole or in part, until a
self-determined cap determination is filed
Data Submission for Quality Reporting
• Data Submission Requirements under the
Hospice Quality Reporting Program.
– Hospices must submit to CMS data on
measures selected in a form and manner, and at
a time, specified by the Secretary.
Submission of HIS data
• Submission of Hospice Quality Reporting
Program data.
– Complete and submit an admission Hospice
Item Set (HIS) and a discharge HIS for each
patient admission to hospice, regardless of
payer or patient age.
– HIS is a standardized set of items intended to
capture patient-level data.
Contract with CAHPS® Vendor
• Medicare-certified hospices must
contract with CMS-approved vendors to collect
the CAHPS® Hospice Survey data on their behalf
and submit the data to the Hospice CAHPS® Data
Center.
CAHPS Survey Data Collection
Deaths in Prior
Calendar Year
< 50 deaths
50 to 699 deaths
n = 2,326 hospices
>= 700 deaths
n = 274 hospices
Survey and Reporting
Exempt from CAHPS
data collection and
reporting
Survey and report all
cases
Sample of 700 will be
drawn under equal
probability design
Quality Reporting Appeals
• Reconsiderations and appeals of Hospice
Quality Reporting Program decisions.
– May request reconsideration of a CMS decision
about Hospice Quality Reporting Program for a
particular reporting period.
– Reconsideration requests to CMS no later than 30
days from the date identified on the annual
payment update notification provided to the
hospice.
Quality Reporting Appeals
• Reconsiderations and appeals of Hospice
Quality Reporting Program decisions.
– Submission requirements available on the CMS
Hospice Quality Reporting Web site on
CMS.gov.
– A hospice dissatisfied with CMS decision may
file an appeal with the Provider Reimbursement
Review Board
CMS REMINDER: GUIDANCE ON
DETERMINING BENEFICIARIES’
ELIGIBILITY FOR HOSPICE
Eligibility
• Reminder that the hospice medical director
must consider at least the following
information per our regulations at §418.25
(b):
– Diagnosis of the terminal condition of the patient
– Other health conditions, whether related or
unrelated to the terminal condition.
– Current clinically relevant information supporting
all diagnoses.
Resources for Eligibility
• Multiple public sources available to assist in
determining whether a patient meets Medicare
hospice eligibility criteria:
– industry specific clinical and functional assessment
tools
– information on MAC websites
• We expect hospice providers to use the full
range of tools available to make responsible
and thoughtful determinations regarding
terminally ill eligibility
HOSPICE EHR
PARTICIPATION
Feedback on Hospice EHR
• Have hospices have adopted an EHR?
• What functional aspects of the EHR do hospices find most
important?
– ability to send or receive transfer of care Information
– ability to support medication orders/medication reconciliation
• Can hospice EHR communicate with other healthcare
providers?
– acute care hospitals
– physician practices
– skilled nursing facilities? Ins decision
• Should CMS develop electronic clinical quality measures for
hospice providers? Benefits and limitations?
ICD-9 TO ICD-10 CODING AND
TIMELINE
ICD-9
• ICD-9-CM diagnosis codes will continue to
be used for hospice claims reporting until
October 1, 2015
• Diagnosis reporting on hospice claims must
adhere to ICD-9-CM coding conventions
and guidelines
• Applies to both the principal diagnosis and
the reporting of additional diagnoses
Medicare Code Editor Edits
• Will implement certain edits from Medicare
Code Editor (MCE)
• Report errors in the coding of claims data
• ALL hospice claims effective October 1, 2014
or later
• Inappropriate principal or secondary diagnosis
codes, per ICD-9-CM coding conventions and
guidelines?
• Returned to Provider (RTP) for correction and
resubmission prior to payment
Multiple Diagnoses on Claim
Year
FY2010
% of claims
submitted with one
diagnosis
77.2%
First quarter (10/1/2012 72%
through 12/31/2012)
FY2013
67%
COMMENTS REQUESTED BY
CMS FOR FUTURE
RULEMAKING
CMS REQUESTED COMMENTS ON
DEFINITIONS OF “TERMINAL
ILLNESS” AND “RELATED
CONDITIONS”
Definition of Terminally Ill
• CMS states:
“Because hospice care is unique in its
comprehensive, holistic, and palliative
philosophy and practice, we want to
ensure that the hospice services under
the Medicare hospice benefit are
preserved and not diluted, or
unbundled in any way.”
Possible Definition of Terminal Illness
• “Abnormal and advancing physical, emotional, social
and/or intellectual processes which diminish and/or
impair the individual’s condition such that there is an
unfavorable prognosis and no reasonable expectation of
a cure;
• not limited to any one diagnosis or multiple diagnoses,
but rather it can be the collective state of diseases and/or
injuries affecting multiple facets of the whole person,
are causing progressive impairment of body systems,
and there is a prognosis of a life expectancy of six
months or less”.
Possible Definition of Related Conditions
• “Those conditions that result directly from
terminal illness; and/or
– result from the treatment or medication
management of terminal illness; and/or
– which interact or potentially interact with terminal
illness; and/or
– which are contributory to the symptom burden of
the terminally ill individual; and/or
– are conditions which are contributory to the
prognosis that the individual has a life expectancy
of 6 months or less”.
CMS REQUESTED COMMENTS
ON COORDINATION OF
BENEFITS PROCESS AND
APPEALS PART D PAYMENT FOR
DRUGS WHILE BENEFICIARIES
ARE UNDER A HOSPICE
ELECTION
Comments Requested on Possible Changes to
Part D Regulations
• Would require that a Part D sponsor
communicate and coordinate with Medicare
hospices in determining coverage for drugs
whenever
– a coverage determination process is initiated or
– a hospice furnishes information regarding a
beneficiary’s hospice election and/or drug
profile
Comment on Hospice Initiated Communication
• Report a beneficiary’s hospice status
• Includes
– notice of election (NOE)
– Notice of termination/revocation (NOTR)
• May also provide
– drug profile information
– identification of drugs unrelated to the terminal
illness or related conditions
– explanation of why the drug is unrelated
Comment on Hospice Initiated Communication
• Permits hospices to initiate communication
with the beneficiary’s Part D sponsor
• Considering requiring Part D sponsors to
accept NOE and NOTR information as use
for coverage until official CMS notification
is received
• Expect sponsors to have processes in place
to confirm CMS-reported data and
communicate with hospice
Comment on Part D Sponsors using Proposed
Definitions
• Propose that Part D sponsor be required to
use the criteria described in the definitions
of “terminal illness” and “related
conditions”
• Determine whether drug is unrelated to the
terminal illness and related conditions
• Satisfies the beneficiary-level hospice PA
Comment on Independent Review Process
• CMS considering
• Separate and distinct from the enrollee
appeals process
• Independent Review Entity (IRE) decision
would be binding on both the Part D
sponsor and the hospice
HOSPICE COORDINATION OF
PAYMENT WITH PART D
SPONSORS AND OTHER PAYERS
Reports from Beneficiaries
• Anecdotal reports from Medicare hospice
beneficiaries
• They are not receiving medications related
to their terminal illness and related
conditions from their hospice
• One reason stated – “those medications are
not on the hospice’s formulary”
Hospice Formulary
CMS states:
• If the drugs on the hospice formulary are
not providing the relief needed, then the
hospice must provide alternatives in order
to relieve pain and symptoms
• EVEN if it means providing drugs that are
not on the hospice formulary
CoP for Drug Coverage
• 418.202(f),
– Hospices are to cover all drugs which are
reasonable and necessary to meet the needs of
the patient in order to provide palliation and
symptom management of the individual's
terminal illness and related conditions.
• Treatment decisions should be driven by
clinical appropriateness, rather than costs
CMS Comment on Medication Management
CMS states:
– Hospices should use thoughtful clinical
judgment, with a patient-centered focus, when
developing the hospice plan of care, including
the recommendations for medication
management
PART D AND HOSPICE
HTTP://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FORSERVICE-PAYMENT/HOSPICE/DOWNLOADS/2015-PART-DHOSPICE-GUIDANCE.PDF
What we know
• Ongoing meetings on Part D and hospice
with no easy resolution
• Part D plans instructed to continue current
practices through 2015
• Some hospices continue to request Part D
payment for vitamins, calcium, nasal spray
and throat lozenges
• Some Part D plans refuse to pay for any
drugs for hospice patients
Relatedness
• No clear line between related and unrelated
to terminal illness and related conditions
• Could be contributing to prognosis…
• Determination needs:
– Expertise of hospice physician
– Documentation in medical record of “why” the
drug is unrelated
Four Buckets of “Relatedness”
RELATED
and
HELPFUL
26
RELATED, BUT
NO LONGER
HELPFUL or
NOT ON
FORMULARY
UNRELATED
and
HELPFUL—
PART D
COVERS
UNRELATED,
BUT NO
LONGER
HELPFUL
Standardized Form
• Developed by the National Council of
Prescription Drug Programs (NCPDP)
• CMS has stated that they have reviewed the
form and “tweaked” it in a couple of places
• Will begin sending it through the
Paperwork Reduction Act (PRA) process
for approval
• May take years…
Quality Reporting
ACA
(HEALTH REFORM LEGISLATION)
• Requires hospices to submit data on selected quality
measures to receive annual payment update for fiscal
year 2014 and subsequent fiscal years.
• Beginning in FY 2014, hospices that do not submit
required quality measure data will have their market
basket rate reduced by 2% for that FY.
ACA
(HEALTH REFORM LEGISLATION)
• CMS must take steps to make hospice quality
measure data available to the public (no timeline
given).
• The published quality measures must receive
endorsement from a consensus body (e.g. NQF),
with exceptions.
FIRST TWO YEARS
Measures
1. NQF #0209:
Comfortable Dying = Percentage of patients who
were uncomfortable because of pain on the initial
assessment (after admission to hospice) whose pain was
brought to a comfortable level within 48hours
FIRST TWO YEARS
2. Structural Measure:
Participation in a QAPI program that
includes at least 3 quality indicators
related to patient care
2014 FINAL RULE
Data collection and submission for QAPI Structural
measure and NQF 0209 are discontinued
CY 2013 was the last data collection; CY 2014 was the
last data submission for these measures
FY 2015 is the last payment determination year for
these measures
2014 QUALITY REPORTING
NQF #0209 and QAPI Structural Measures –
No longer required for quality reporting
*Comfortable Dying measure still supported by
NHPCO
QUALITY REPORTING - HIS
Hospice Item Set (HIS)
• Patient level data collection tool
• Data used to calculate 7 new measures
QUALITY REPORTING - HIS
Six NQF Endorsed Measures:
NQF 1634
Hospice and Palliative Care -- Pain Screening
NQF 1637
Hospice and Palliative Care –Pain
Assessment
NQF 1638
Hospice and Palliative Care -- Dyspnea
Treatment
NQF 1639
Hospice and Palliative Care -- Dyspnea
Screening
QUALITY REPORTING - HIS
Six NQF Endorsed Measures:
NQF 1617
Patients Treated with an Opioid who are
Given a Bowel Regimen
NQF 1641
Treatment Preferences
One Modified NQF Measure:
NQF 1647
Beliefs/Values Addressed
QUALITY REPORTING - HIS
For specifications of proposed measures -National Quality Forum (NQF)
Final Report on Palliative and End of Life Measures
http://www.qualityforum.org/Projects/Palliative_Care_and_Endof-Life_Care.aspx#t=1&s=&p=
(or Google search: NQF Palliative end of life measures
endorsement summary)
QUALITY REPORTING - HIS
• Implementation starts July 1, 2014
• Hospices who fail to report quality data via the
HIS system in 2014 will have a 2% market basket
reduction for FY2016
• Reconsideration request process
QUALITY REPORTING - HIS
All Medicare-certified hospices must submit.
• New but on track for initial survey – need to prepare
• Newly certified hospices that receive notice of their
CMS certification number on or after November 1,
2014 excluded (proposed)
QUALITY REPORTING - HIS
Must collect and submit data on admission and
discharge of every patient
• All payers
• All ages
QUALITY REPORTING - HIS
Quality measure scores not calculated for all
patients  18 years and older
 LOS of > 7 days for some
But still need to collect/submit for all
admissions starting 7/1/2014
QUALITY REPORTING - HIS
Two Forms
ADMISSION
• Sections A, F, I, J, N, Z
• Contains administrative items and care process items.
DISCHARGE
• Sections A, Z
• Contains a limited set of administrative items and 2
discharge items.
QUALITY REPORTING - HIS
The HIS is not –
a patient assessment instrument and will not be
administered to the patient and/or family or caregivers
The HIS is a standardized mechanism for abstracting data from the
medical record
QUALITY REPORTING- HIS
Record Completion and Data Submission
• Electronically online
• Ongoing basis
• 14 days from admission to complete HIS-Admission
record
• 7 days from discharge to complete HIS-Discharge record
• 30 days from a patient admission or discharge to submit
QUALITY REPORTING- HIS
Have policy/procedure in place related to:
 Creation of HIS
 Retention of HIS submission
QUALITY REPORTING - HIS
CMS Resources – Data Collection
CMS HQRP Web site – Hospice Item Set page
– HIS Manual and Change Table
– HIS Training slides
– Fact Sheet
– Q&A
http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-QualityReporting/Hospice-Item-Set-HIS.html
Quality Help Desk:
[email protected].
QUALITY REPORTING - HIS
CMS Resources – Data Submission
CMS HQRP Web site - HIS Technical
Information page
QTSO Website
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Technical Training modules (Webex)
HART Training modules
Registration for IDs
https://www.qtso.com/hospice.html
https://www.qtso.com/hart.html
Technical Support
QTSO Help Desk: [email protected]
HOSPICE CAHPS
(EXPERIENCE OF CARE SURVEY)
• Post-death caregiver survey
• Consumer Assessment of Healthcare Providers and
Systems (CAHPS) family of surveys
• Borrows heavily from NHPCO FEHC
• Requires contract with a vendor for survey
administration
HOSPICE CAHPS
Implementation
Mandatory “dry run” for at least 1 month in first quarter
of CY 2015
• Continuous participation starts April 1, 2015
• Participation will affect the FY 2017 payment
determination year
• Dedicated survey website (TBA)
• Reconsideration request process
• Will be included in public reporting eventually
HOSPICE CAHPS
Eligibility:
•
•
•
•
•
•
Patients over age of 18
LOS of at least 48 hours
No non-familial legal guardians
No non-USA home addresses
No known caregiver or contact information
Request not to be contacted
HOSPICE CAHPS
• Must use a vendor approved by CMS
• List of approved vendors provided close to
the launch of national implementation.
• Summer 2014 interested vendors may apply
to become an approved vendor
HOSPICE CAHPS
Measures derived from survey questions:
1. Hospice Team Communication (5)
2. Getting Timely Care (2)
3. Treating Family Member with Respect (2)
4. Providing Emotional Support (2)
Source = proposed rule
HOSPICE CAHPS
5. Getting Help for Symptoms (4)
6. Information Continuity (1)
7. Understanding the Side Effects of Pain
Medication (1)
8. Getting Hospice Care Training (Home
Setting of Care Only) (4)
Source = proposed rule
HOSPICE CAHPS
Sampling:
• Hospices send caregiver information to vendors each month
• Hospices with fewer than 50 decedents during the prior calendar
year are data collection and reporting requirements for payment
determination.
• Hospices with 50 to 699 decedents in the prior year (n = 2,326
in 2012) will be required to survey all cases.
• For large hospices with 700 or more decedents in the prior year
(n =274 in 2012), a sample of 700 will be drawn under an equalprobability design.
Change Requests (CRs)
July 2013 through
June 2014
Medicare Benefit Policy Manual
Chapter 9 - Coverage of Hospice Services
Under Hospital Insurance
(Rev. 156, 06-01-12)
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp
102c09.pdf
CR 8727 Updates and Clarifications to the
Hospice Policy Chapter of the Benefit
Policy Manual
Released May 1, 2014
Effective Date: August 4, 2014
• Updates the hospice policy chapter to incorporate
policy language from existing regulations, prior
rules, an OIG report and two CR, and to clarify
existing policy. No changes were made to existing
policy.
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2014-TransmittalsItems/R188BP.html
CR 8620 CWF Editing for Vaccines
Furnished at Hospice - Correction
Released February 6, 2014
• Was rescinded and replaced by Transmittal
1737, dated April 28, 2014
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/
R1339OTN.pdf
CR 8569 Enforcement of the 5 day
Payment Limit for Respite Care Under
the Hospice Medicare Benefit
Released February 5, 2014
• Was rescinded and replaced by Transmittal
2928 to restore information from CR8358
that was erroneously omitted.
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/
R2867CP.pdf
CR 8358 Additional Data Reporting
Requirements for Hospice Claims
Released January 31, 2014
• To provide clarifying information and
examples; technical corrections of
Transmittal 2747, dated July 26, 2013
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/
R2864CP.pdf
CR 8358 Additional Data Reporting
Requirements for Hospice Claims
Released July 26, 2013
Effective Date: April 1, 2014
Implementation Date: January 6, 2014
• Additional date for: visit reporting for GIP,
reporting facility NPI; reporting of infusion
pumps and prescription drugs
http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/Hospice/Downloads/R2747CP.pdf
Provider Bulletins (PBs)
July 2013 through
June 2014
Provider Bulletin 13-65
FFY 2014 Medicaid Hospice Rates
• Issued: September 9, 2013
• Effective Date: October 1, 2013
http://dhhs.ne.gov/medicaid/Documents/pb13
65.pdf
Provider Bulletin 13-79
January 1 through December 31, 2014 Base
Rates for Levels 101 through 105
• Issued: December 11, 2013
• Effective Date: January1, 2014
http://dhhs.ne.gov/medicaid/Documents/pb13
79.pdf
Provider Bulletin 14-21
Provider Enrollment Process Changes
• Issued: April 2, 2014
• Effective Date: May 1, 2014
http://dhhs.ne.gov/medicaid/Documents/PB%
2014-21.pdf
Provider Bulletin 14-22
Nebraska Medicaid Recovery Audit Contract
(RAC) Program
• Issued: April 29, 2014
http://dhhs.ne.gov/medicaid/Documents/pb14
22.pdf
Revalidation of Provider Enrollment
All providers and suppliers enrolled with
Medicare prior to March 25, 2011, must
revalidate their enrollment information, but
only after receiving notification from their
MAC.
Revalidation of Provider Enrollment
• Letters to be sent between now and
6/23/2015
• Will be mailed (USPS) to address on file
CMS website
http://www.cms.gov/MedicareProviderSup
Enroll/
Hospice
Scrutiny
Office of Inspector General (OIG)
Fiscal year 2014 work plan related to hospice:
• Hospice in assisted living facilities
– ALF residents have the longest lengths of stay in hospice care
• Hospice General Inpatient Care
– Review the appropriate use of hospice general inpatient care
http://oig.hhs.gov/reports-andpublications/archives/workplan/2014/Work-Plan-2014.pdf
MedPac
March 2014 Report
Recommendation to “carve-in” the Medicare
Hospice Benefit for Medicare Advantage
participants
HealthDataInsights, Inc.
RAC for Region D
• Listed audit issue for hospice
– Face-to-Face Evaluation for Re-certification of
Hospice Care
• Medical documentation will be reviewed to
determine timeliness of the face-to-face recertification
https://racinfo.healthdatainsights.com/Public1/
NewIssues.aspx
PEPPER
Program for Evaluating Payment
Patterns Electronic Report
Hospice Target Areas
Live Discharges
Long Length of Stay
PEPPER
A report summarizing a hospice’s Medicare
claims data in areas of risk.
• Compares a hospice’s claims data with
aggregate statistics for other hospices in the
state, MAC/FI jurisdiction and the nation
• Data obtained from the UB-04
PEPPER
PEPPER does not identify the presence of improper
payments, but can be used as a guide for auditing
and monitoring efforts
Training and Resources:
http://pepperresources.org/TrainingResources/
Hospice.aspx
Fiscal Intermediary
Information
CGS
1-877-299-4500
Option 1: Hospice Customer Service Rep
Option 2: EDI Customer Service Rep
Option 3: Provider Enrollment department
Option 4: Overpayment Recovery department
Interactive Voice Response (IVR) number
1-877-220-6289 for beneficiary eligibility,
claim status, check and general information
myCGS Web Portal
• New enhancements
• If your organization/office is not already
signed up for the myCGS web portal, go to
http://www.cgsmedicare.com/mycgs/index.
html
CGS
Claims Denied
February 2014 – May 2014
277,779 hospice claims submitted
43,488 claim submission errors
3,406 hospice claims reviewed
2,164 denied
CGS Hospice Medical Review
Top Denials for February – May 2014
5PTER: Six-month prognosis not supported
5PPOC: Plan of care not updated timely
5PCER: Certification requirements not met
56900: ADR information not received
5PNOE: Election Statement incomplete, missing,
untimely
Medical Review Hierarchy
Level of
care
Physician visits
Terminal status
Plan of Care (POC) including
review of the POC every 15 days
Certifications including face-to-face
(FTF)
Election Statement
CGS Current Widespread Edits
• Length of stay > 730 days
• Seven or greater GIP days on claim
• Code Q5003 and Q5004 with primary diagnosis of
Debility, unspecified (799.3) and length of stay >
180 days
• Length of stay between 150-365 days and nononcologic diagnosis code
• Previous denials for selected beneficiary
http://www.cgsmedicare.com/hhh/medreview/med_r
eview_edits.html
Additional Document Request
(ADRs)
• Check for ADRs at least once per week
ADR Quick Reference Tool
http://www.cgsmedicare.com/hhh/education/
materials/pdf/ADR_QRT.pdf
Chapter 3: Inquiry Menu
http://www.cgsmedicare.com/hhh/education/
materials/pdf/Chapter3_Inquiry_Menu.pdf
Resources
CGS
http://www.cgsmedicare.com/hhh/index.ht
ml
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Frequently asked questions
Education materials (Quick Reference Tools)
Claim information
E-mail list serve
Resources
CMS Hospice Center
http://www.cms.gov/Center/ProviderType/Hospice-Center.html
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CMS Q&A
Change Requests and Transmittals
CMS manuals
MLN Matters Articles
Open Door Forum
Resources
Nebraska Hospice and Palliative
Care Association
nehospice.org
Membership Only Section
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Password: nhpca2013