Palmetto GBA Hospice Coalition Questions and Answers February 12, 2008
To: From: Date: Location:
Hospice Coalition Members Palmetto GBA Provider Education February 12, 2008 Palmetto GBA
NOTE: Palmetto GBA strives to provide timely and accurate answers to coalition questions. Coalition questions and answers are reviewed by several departments at Palmetto GBA to ensure a thorough answer is given during the meeting and posted in the coalition minutes. In order to continue to provide excellent service to our members and providers, questions for the Hospice Coalition meetings MUST be submitted to Krisdee Schmale within 14 business days of the meeting. Questions submitted after 14 business days will be answered at the next coalition meeting. Attachments Attachment A: Attachment B: Attachment C: Attachment D:
PCA Decision Tree 2006 Hospice Overpayments by State 2008 Palmetto GBA Hospice Workshop Schedule Appeals Report
Medical Review 1) How can hospice providers access Palmetto claims data (per provider, per state, etc.) used to make determinations about which issues are selected for edits and which providers are included in those probes? Looking for the data on average length of stay, non cancer patient numbers, average number of days GIP was billed for, percentages of discharges due to other than death, amount of payments to physicians for inpatient visits, etc. Information would need to be requested through the Freedom of Information Act (FOIA). A FOIA request should be made in writing. A short and simple letter will suffice. It should be signed. It should state that the request for information is being made under the FOIA. The letter should specify the information being requested. The name, address and telephone number of the requester should be clearly indicated. A fee may be assessed to cover some or all of the processing costs.
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All FOIA requests for information from Palmetto GBA should be sent to: FOIA Coordinator PO Box 100190 Mail Code AG-270 Columbia, SC 29202-3190 Requests may also be faxed to (803) 935-0248. At this time, Palmetto GBA cannot respond to FOIA requests over the Internet. 2) Regarding the current NCLOS probe that is ongoing. Programs have been placed on extended review for a charge denial rate of >15% and are requested to submit 25% of their charts for the next quarter. However, not all these submitted charts are being reviewed, and we have been told that the decision to continue at this percentage rate is based on the review of only a sample of the submitted charts. For example, I have been told that a program submitted 150 charts and the decision to continue at 25% review was based on a 20 chart sample. How is this statistically valid, and how does this justify the extensive labor involved in producing these charts for review? The most recent NCLOS probe has been completed. Providers with a charge denial rate of 15% or greater are usually progressed to complex review. Under normal circumstances a provider’s claim suspense rate is equal to their charge denial rate. For hospice providers, if the charge denial rate is greater than 25% the claim suspense rate will not exceed 25%. This does not include beneficiary specific edits. The Program Integrity Manual does not state that the claim suspension rate be a statically valid sample. The percentage should be based on the significance of the errors identified. Palmetto calculates the charge denial rate based on the claims reviewed in the probed sample and uses that percentage to determine the amount of review. Because of the number of providers identified during this probe review as having a charge denial rate of greater than 15%, Medical Review made a decision to set all of the edits at 10%. If a provider had 150 claims selected in a three-month period that equates to an average of 50 claims per month, which indicates they are billing approximately 500 claims each month. The claims suspended would also include any beneficiary specific edits. For them to have been placed on complex review, their charge denial rate would have to have been greater than 15%. If their edit had been set based on the normal practices, the number of claims suspended for review would have been at least 75 per month or 225 in the three month period if the claim suspension rate was at 15%.
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3) Please help once again with a clear detailed explanation for how to calculate the NCLOS rate. I understand the basic principle of the number of patients for a specific non-cancer diagnosis greater than 210 days divided by the total, but when I requested our rates they gave them by the quarter. I want to be able to do regular internal checking to provide careful monitoring of our organization. Are they calculated by quarter or every six months? What is the formula? Palmetto GBA calculates and publishes Non-Cancer Length of Stay (NCLOS) Rates semi-annually, not by quarter. Palmetto GBA has described various types of NCLOS rates. o All Categories: Population - All non-cancer claims subject to the non- cancer hospice LCDs, for all identified providers.
Provider-specific - All non-cancer claims subject to the noncancer hospice LCDs, for a single provider.
o Policy-Specific: Population - All non-cancer claims subject to a single noncancer hospice LCD, for all identified providers.
Provider-specific - All non-cancer claims subject to a single non-cancer hospice LCD, for a single provider.
Regardless of the type of NCLOS rate the formula remains: Number of non-cancer beneficiaries with LOS >210 Total number of non-cancer beneficiaries NCLOS Rate values may range from 0, no beneficiaries had lengths of 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). http://www.palmettogba.com/palmetto/providers.nsf/44197232fa851689852571 96006939dd/85256d580043e75485257359004d6275?OpenDocument 4) If we discharge a patient when they are determined to no longer be hospice eligible, does this trigger an ADR? And if so, does this result in an automatic denial of the last claim submitted? If claims for this beneficiary were previously reviewed and denied, a beneficiary edit may have been established. If so, all claims for that beneficiary will be selected for review. Selection for review does not automatically generate a denial. All claims are medically reviewed based on the information submitted for the date of service in question.
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5) Why are claims being denied for functioning, structure and disability (ICF) when we were never told this language was mandatory? While there seems to be value in the ICF and we are certainly moving forward in our utilization of the ICF it has been a great, time consuming, and costly burden to undertake with minimal instruction and guidance. We are a small program with limited monies as it is and this Review process is devastating. Once you are in, you are in for at least a year it seems. Is there a way to shorten this process? Medical review is not denying claims for failure to use the ICF language. There is no mandatory requirement to use the ICF language. The length of time a provider is on medical review is determined by many factors. The time spent in probe review varies based on the billing practices of the provider. For example, to obtain a 20-40 claim sample would naturally be longer with a provider billing only 5 claims per month as opposed to one billing 50 per month. The sooner the sample is collected, and the sooner the provider responds the quicker the review can be completed. When the sufficient number of claims has been reviewed and processed, the charge denial rate can be calculated and the results reported to the provider. Once a provider has an acceptable charge denial rate the edit is discontinued. Beneficiary edits remain in place until a decision is made that it is no longer needed. In order to shorten the process, providers should review any and all feedback given to them related to errors identified through the medical review of the claims. Providers should be monitoring the Palmetto GBA website for updates, changes in regulations and articles published related to medical review (e.g. updates on signatures, top denials, and TIP letters). Providers should also insure that claims being submitted have the appropriate documentation to substantiate the services billed and this documentation should be on file prior to billing. These actions will decrease medical review denials, decrease the time it takes to respond to an ADR and decrease the likelihood of being placed on complex review or aid in being removed from complex review after the first quarter. 6) On several Medicare Redetermination Decisions for patients with Alzheimer’s/dementia, in the Explanation of the Decision area, the only reason for denial was that the documentation did not support the severity of co-morbidities. The decision stated that this was because these co-morbidities did not meet their own LCD criteria. For example, perhaps the Alzheimer patient had CHF but was not yet NYHA Class IV, since that patient was not a Class IV the patient did not fully meet the Heart LCD criteria and so was denied on the Alzheimer’s criteria as not having sufficient co-morbidities. It appears that these patients had to meet two LCD criteria set to be appropriate under the Alzheimer’s LCD. Is that the intent of the decision, to hold Alzheimer patients to two criteria sets?
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The procedure for reviewing hospice cases in the Appeals Department is to first look for the admission diagnosis. If the beneficiary does not meet the criteria for this diagnosis, then the reviewer will look at all existing co-morbid conditions to determine if the claim can be paid. It is not the policy or intent of the Appeals Department that the beneficiary would meet all criteria for all diagnoses listed. If the provider will submit the specific case information to the Appeals Manager, then a review of the cases in question can be discussed. 7) On the initial denial of an ADR the provider receives very little information as to why that claim was denied. Then after the redetermination review, if the finding is unfavorable, then the provider receives a more detailed explanation of the reasons for the denial. Why is it that Palmetto does not provide this detailed information at the first denial? It would help providers better understand why they are being denied, what changes the organization may need to make to improve compliance, and what educational opportunities exist to help ensure the provider’s staff understand the requirements as defined by the intermediary. An explanation is entered in the remarks field on page 4 of DDE for each claim denied by medical review. Providers are encouraged to view this information to determine the specific reason for the medical review denial. If additional information is needed, the provider can call the medical review message line at 803-763-7491 and leave a detailed message including the provider contact name, provider number, contact phone number, the beneficiary’s name, HICN, dates of service and the nature of the call. A Medical Review representative will return the call to assist them in understanding the reason for the denial. Note: The medical review phone line is for issues related to claims reviewed by the Medical Review Department. All other inquiries should be directed to the Provider Contact Center (PCC), which is available for Regional Home Health and Hospice Intermediary (RHHI) providers from 8:00 a.m. to 5:00 p.m. EST, Monday through Thursday, and Friday 8:00 a.m. to 2:00 p.m. and 4:00 p.m. to 5:00 p.m. EST. You may contact the RHHI PCC at 1-866-801-5301. 8) In the explanation section of ADR denial letters, some reviewers for both Palmetto and the QIC seem to imply that if a patient can ambulate, the patient’s Palliative Performance Scale rating would be 50% rather than 40%. Since the Ambulation column for the PPS says “mainly in bed”, this does not preclude being able to ambulate for short periods of time. Please explain what training Palmetto and QIC reviewers have had in understanding and properly using the PPS and other tools (e.g. FAST) that are part of Palmetto Hospice LCDs. Palmetto GBA reviewers use the guidance provided by the developers of the Palliative Performance Scale, the Victoria Hospice Society. The guidance is available on-line at: http://www.victoriahospice.org/pdfs/PPSv2.pdf
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With regard to the FAST Scale, Palmetto GBA uses the scoring guidelines contained in the original article by Dr. Reisberg (Reisberg B Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 24: 653-659, 1988). 9) Please explain and clarify the various steps and phases of all the ADR/Denial processes as it is not completely clear in the Training Manual especially related to length of phases. The PCA Decision Tree is attached for your review (Attachment A). For provider specific review, the initial phase is a probe review. This involves individual providers that meet the specific criteria identified in the data analysis performed. Each provider selected for the review is notified in writing. The notification letter includes an explanation of the purpose of the review, how the process works, and contact information. The review consists of a sampling of 20-40 claims. Once the appropriate number of claims are reviewed and processed, the determination of whether the medical review is discontinued or resumed is based on data analysis of the reviewed and processed claims. The result of the data analysis is expressed as a percentage and is identified as a charge denial rate (CDR). The CDR is calculated as the Total charges denied/re-coded on the number of claims reviewed and processed divided by the total charges on the number of claims reviewed and processed multiplied by 100 = CDR. Once the percentage is determined, a decision to discontinue or resume the medical review is discussed. Generally, the following criterion is used to assist in making these determinations: •
CDR of 0% - 15% -medical review is discontinued
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CDR of 16% - 50% - (phase II) medical review is resumed for a threemonth quarter. If the CDR remains above 15% after the three month quarter, the provider moves to the Corrective Action Plan (CAP) phase
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CDR of 51% - 100% - (CAP) medical review is resumed and a written CAP is requested from the provider and the CDR will be recalculated at the end of each quarter. Review is continued until the provider CDR is reduced to an acceptable level.
10) Now that we have been notified we are in Qtr 2, Phase 2 of the Probe Edit, where can we find information on these Phases since we are unfamiliar with the “Phases”? Please see question #9
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11) What is the process to notify a provider that they are continuing on medical review. We received a letter on 1/7/08 with a 12/13/07 date indicating a continuation of the review. This is 3 weeks after the date of the letter. For another provider number, we never received a letter via mail at all and had to call Palmetto to have it faxed to us on 1/14/08. What can be done to improve timely notification to providers? Make sure that the provider address in FISS is correct; ensure that provider staff knows where letters are to be directed. Please note that if mail is returned and a valid address is secured the letter will be resent but the dates of the letters will not change. If a valid address cannot be obtained the letter is placed in a file and maintained until contact with the provider is made. This does not delay or prohibit the initiation of review. In most cases provider will contact the Medical Review Department and notification are directed to the appropriate provider contact. 12) Are there any current edits in place? Beneficiary edits and providers that are on complex review continue. New providers are also reviewed when appropriate. 13) What plans does Palmetto GBA have for future edits? Based on CERT data, results of the last NCLOS probe and follow up to the hospice cap provider project, hospice edits will be initiated focusing on these areas. The numbers of providers, the specific services or individual states have not been identified at this time. As always, providers specifically selected for review will be notified in writing. If it is a service specific edit, notification will be communicated through the Palmetto GBA website. 14) Please provide an update on NCLOS review which began in November 2006 including numbers of providers on edit, on phase 1 and on phase 2, numbers still on, top 5 reasons for denial and any other information related to this edit. Provider Initial Selection Count Number of providers identified for review 252 Number of providers reviewed (two providers terminated from Medicare 250 billing)
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Outcome Number of providers progressed to phase II Number of providers going straight to cap Number of providers educated and removed following the probe review Number of providers discontinued following the probe review
Provider Count 153 32 36
29 Provider Current Status Count Number of providers currently on probe 0 Number of providers currently in phase 42 II Number of providers currently on cap
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CR5567 15) Our homemakers are all also CNAs. If they make a visit and perform services that are both homemaker services and CNA services, do we count that as two visits since the kind of services provided are different? No. The total number of visits does not imply the total number of activities or interventions provided during the time a CNA is in the home. If the CNA performs multiple activities or interventions during the course of a visit, then only one visit is counted. If, however, the CNA leaves the home and later returns to the patient’s home to perform additional activities or interventions, then another visit would be counted. Note: Homemaker service data is not currently being captured. 16) If the services were provided by different staff or at different times would it be counted as separate visits for example, how about other staff who represent more than one discipline, like a RN who is also a Social Worker? Question #10 in the CMS questions and answers on the CMS Web Site at www.CMS.hhs.gov addresses this question. “The information on the claims does not identify what type of service is being provided, but merely identifies the number of visits by care provider type. Therefore, the visits provided by a licensed nurse would be reported as nursing visits.”
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17) What should be included in determining the charge per visit by discipline? Should it include the cost of supplies used during the visit? Mileage expense associated with the visit? Cost of creating and maintaining the medical record? Cost of the computer system if the record is electronic? Management and administrative costs that are needed to support every visit? Essentially all allowable costs of a hospice go to support the provision of patient care in some way and therefore contribute to the cost of each visit. Please clarify what CMS expects us to include in the visit cost. Each hospice is responsible for determining the total charge for each discipline. Medicare contractors do not have the authority to mandate or instruct providers on what they can charge for services they provide to beneficiaries. 18) In the Palmetto GBA slide presentation entitled “Hospice Changes Effective January 1, 2008,” the 18th slide lists “Social Worker visits not involving the beneficiary” as an example of a visit that is not direct patient care and therefore should not be counted. However, in a CMS Q&A published 12/20/2007, the answer to question 6 indicated that “counseling or speaking with a patient’s family or arranging for placement would constitute a visit.” These appear to give different instructions. Please clarify what constitutes a medically reasonable and necessary social worker visit.
Palmetto GBA has received clarification from CMS regarding this issue. A medically reasonable and necessary direct patient visit by a social worker is a visit that is reasonable and necessary for the palliation and management of the terminal illness and related conditions as described in the patient’s plan of care. A social worker differs from other disciplines and their direct care may not always involve having the patient present in the room. Therefore, due to the nature of a social worker’s functions, counseling or speaking with a patient’s family or arranging for placement, would constitute a visit. 19) How does a hospice keep track of visits at the GIP level of care when the care is fluid? No other inpatient care settings or providers (i.e. hospitals, SNFs) are required to count the number of “visits” they make to a patient room, how and why does hospice? Question #2 in the CMS questions and answers on the CMS Web Site at www.CMS.hhs.gov regarding CR5567 states the following: “The Medicare hospice benefit was implemented in 1983. Since that time, the benefit has grown considerably. Unlike other payment systems, hospice providers have had to provide minimal information on the hospice claim. The Office of the Inspector General (OIG), the General Accounting Office (GAO) and the Medicare Payment Advisory Commission (MedPAC) all recommended that CMS collect more comprehensive data in order to better evaluate trends
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in utilization of the Medicare hospice benefit. This additional information will help to provide a better understanding of the types and frequency of hospice services provided during a day of hospice care.” Question #4 in the CMS questions and answers addresses the following: “The program transmittal indicted the need to count the number of direct patient care visits provided to Medicare beneficiaries. Hospice providers should create a mechanism that allows for counting how many times a nurse, aide, social worker or physician sees a patient for the purpose of providing a necessary direct patient service. Typical mechanisms used by other health care providers include using paper check lists which are tallied each day or computer-based models. For example, a nurse sees a patient, for the purpose of taking vital signs, administering medications, auscultation of the patient’s chest and change dressings. This would constitute one visit. We expect hospice providers to continue to provide care to patients in a medically appropriate manner. It is not appropriate to break these tasks up into multiple visits for the purpose of inflating the patient’s visit count for that day.” 20) Please clarify which inpatient settings and levels of care require visit reporting. In the CMS Q&A published 12/20/2007, the answer to question 19 indicates that for patients receiving routine home care in nursing homes, the “number of visits to be included on the claims form is the number of visits provided by the hospice staff.” However, in the same document, question 4 asked “How should hospice providers count patient visits in a facility that is staffed 24 hours a day?” and the answer stated that hospice providers should “create a mechanism that allows for counting how many times a nurse, aide, social worker or physician sees a patient for the purpose of providing a necessary direct patient service.” Since nursing homes are facilities staffed 24 hours a day, these two answers seem to conflict. Under what circumstances are we required vs. not required to report visits? Is the differentiating factor perhaps whether the hospice has contracted with the facility to provide the General Inpatient level of care? Palmetto GBA has received clarification from CMS regarding this issue. Hospice providers, in compliance with the Conditions of Participations, are responsible for any contracted services. If the hospice is contracting with a facility to provide the inpatient services and they include the RN, LVN etc., these direct patient care visits are required to be accounted for. The hospice would not report the nursing facility staff’s custodial care any more then they would the family’s custodial care.
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21) Will CMS be giving the fiscal intermediaries better clarification of “medically” necessary visits for patients in a hospital setting? Question #4, #6 and 16 in the questions and answers on the CMS Web Site at www.CMS.hhs.gov addresses “medically” necessary as “a visit that is reasonable and necessary for the palliation and management of the terminal illness and related conditions as described in the patients plan of care.” Further explanation should be requested from CMS. 22) Will hospices have recourse if nursing home and/or hospital administrators refuse to work with a hospice in order for data to be collected for the “medically necessary visits” from the nursing home and/or hospital nurses, aides, and social workers? Hospices retain professional management responsibilities for these services and must ensure that all care provided to the beneficiary while enrolled in the Hospice Medicare Benefit (HMB) is done so appropriately. This includes collecting the data with which to submit claims for the different disciplines. In addition, the CR states, “Hospices are required to report all services, whether provided by hospice employees or provided under arrangement.” Covered Services 23) Hospice patient with lung CA went to the hospital, admitted to the ICU and a vent put in. Hospice was not notified. Is hospice responsible for the costs of the stay, the vent, which is not part of the plan of care? Upon admission, hospice providers are required to develop a written Plan of Care (POC), which should include all services related to the treatment of the terminal illness for which hospice care was elected. In addition, as outlined in the Centers for Medicare & Medicaid Services’ (CMS) Internet Only Manual, Publication 100-04, Chapter 30, Section 50.9, II, hospice providers are required to notify beneficiaries in advance that payment of any services obtained from a facility not authorized by the hospice provider could be the responsibility of the patient. 24) Please clarify medications hospice is expected to cover. There has recently been information stating that hospice is to cover medications for symptom management related to the terminal illness and related conditions. It is the “related conditions” that has caused confusion. The Palmetto Training Manual states 4.2.2.3 Medical Appliances and Supplies, Including Drugs and Biologicals: Drugs used primarily for pain relief and symptom control related to the individual’s terminal illness are covered.
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The Medicare Hospice Conditions f Participation (Title 42-418 Hospice Care: Subpart B,F, and G) Part 418 Hospice Care Subpart F-Covered Services states Medical Supplies, including drugs and biologicals. Only drugs as defined in section 1861(t) of the Act and which are used primarily for the relief of pain and symptom control related to the individual’s terminal illness are covered. Example: Patient admitted to hospice with Ca of lung, Secondary conditions of SOB, Pain, Weakness. Co-Morbid Dx of IDDM (long standing dx). Patient is put on low dose steroid to improve symptoms related to Ca of lung. Side effect of steroid causes increase in blood glucose level and adjustment in Insulin Dose. Is hospice now responsible for supplying Insulin and equipment needed to administer injections? The reference for this subject is found in the CMS Manual Systems Publication 100-2 Medicare Benefit Policy Manual; Chapter 9; Section 40. Implementation date was 06-28-2004. This section states that for an individual to receive covered hospice services, a certification of the individual’s terminal illness must have been completed, and a plan of care must be established before services are provided. Services must be consistent with the plan of care and reasonable and necessary for the palliation or management of the terminal illness and related conditions. ALJ Hearings 25) Regarding ALJ Hearings: a) Do most providers who go before the ALJ have legal counsel with them during the hearing? b) Do the judges that sit for the ALJ hearings have any medical and/or hospice background? c) At each ALJ Hearing, we have been asked very different questions by different judges i.e. Is your agency currently involved in a lawsuit? Is there any way to obtain a preview of the questions that will be asked so we can be better prepared with our answers? When the QIC level of appeal was implemented in May, 2005, all ALJ responsibility was transferred from the Intermediary to the QIC. Palmetto GBA is unable to answer these questions as we currently have no involvement with the ALJ other than to effectuate the ALJ decisions. The East (Maximus) and West (First Coast Service Options) QICS would be the best sources for this information.
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Cap 26) For VA patients with Medicare as secondary, can we zero bill Medicare to have the beneficiary count in the Cap calculations? A zero Medicare bill would be when we bill for days at a zero amount per day. The bill and reimbursement is zero, but the days of service show up in the Common Working File. We do this on insurance patients with Medicare as secondary. We have received different answers for VA, depending who we talk to. I would think that since the VA patient has Medicare as secondary, the days would need to show up in the common working file. For a beneficiary to be counted in the aggregate CAP calculation Medicare reimbursement must have been made on behalf of that beneficiary. To include the VA beneficiary would imply that the VA payments would need to be included in the CAP calculation. Section 80.2 and 80.2.1 from the Internet Only Manual, section 100-4 Chapter 11 notes that the overall aggregate payments made to a hospice for Medicare beneficiaries electing hospice care is counted in the cap calculation. 27) Please give us an update on the 06 Cap demand letters by state. Please See Attachment B 28) How many hospices does Palmetto expect to review for 2006 Cap and how many have been reviewed thus far? There are a total of 1155 hospices that will be reviewed for the 2006 Cap period. As of 2/1/08 722 or 62.5% have been completed. 29) How many Cap demand letters have been sent out thus far, for how much? As of 2/1/08, 133 demand letters have been sent for a total of $122 million in overpayments. 30) How many of the Hospices receiving 06 demand letters thus far exceeded the cap for the first time in 06? Of the 133 providers with overpayments, this was the first year for 47 of these providers to have an overpayment. Of these 47 first time providers, it was the first cap period for 14 of them.
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Payment 31) Can a NH and hospice bill for the same day? A hospice patient revokes hospice on 1/25 and is admitted to the NH as a skilled patient on 1/25. There is a lot of confusion within Medicare/SNF staff advising NH billing personnel that both entities cannot bill the same day of service and are advising the NH must bill using 1/26 or have hospice not bill for the 1/25. Upon revoking the election of Medicare coverage of hospice care for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. Therefore, assuming all other requirements for a Medicare covered stay in a Skilled Nursing Facility (SNF) are met (e.g., 3-day hospital stay), the date of admission could be the same as the date the beneficiary revoked his/her hospice benefit. Hospices should ensure that the revocation notice is submitted to Medicare timely so that the revocation information is posted to the beneficiary’s Medicare records before the SNF submits a claim. Misc 32) Is there any way to find a patient's Medicare number when they are under a spouse's social security number? (Patients become eligible for Medicare while on service and we have the patient's social security number, but we do not have all of their spouses' information). Medicare numbers are usually a social security number with a letter added to it. If a patient's spouse has the coverage then the Medicare number will be under the spouse's social security number. When we have patients that have been married several times it is very difficult to find the social security number, we can usually figure out the added letter. This question should be directed to Social Security. Intermediaries do not look up Medicare numbers. When a provider or beneficiary calls Medicare to obtain information they are asked for to provide their Provider Transaction Access Number (PTAN) and verify name and date of birth. Intermediaries are unable to address questions if this information is not provided. 33) Patients we have discharged tell us they are getting bills for services under regular Medicare after hospice has discharged them. We have made all the entries in our system to terminate the HMB. When they call Medicare, they are told to talk to the hospice. How long should it take for the change to be made and what do we tell these persons? If the discharge claim or the Notice of Termination (8XB) is submitted correctly and on time, the termination date should be posted to the beneficiary’s Master Medicare Record (Common Working File) within three (3) days of the date the discharge bill or Notification of Termination is received. However, providers should note that all claims, including discharge bills or Notices of Termination
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are processed sequentially. Therefore, if claims submitted prior to the discharge bill or Notice of Termination are either selected for medical review or Returned to Provider (RTP) for correction, the processing of the discharge bill or Notice of Termination will not be completed until all previous claims are processed. In addition, providers should ensure that the discharge bill or Notice of Termination is submitted correctly. Discharge bills should contain occurrence code 42 and a Notice of Termination should NOT contain occurrence code 42 or any charges. 34) When a patient received GIP care during the same month his claim was reviewed and then denied; are we responsible for the GIP or physician billing costs or will Medicare pay this under normal benefits for the time the hospice claim was denied? How do we handle this? If a claim that includes days at the general inpatient level of care is denied, does the hospice maintain responsibility for all care and services whether provided directly or under contract during the denied claim period? If a hospice claim including GIP and/or physician services is medically reviewed and denied, the hospice is liable for the charges. These services would not revert to “normal benefits”. Only services not related to the terminal illness would be covered outside the hospice benefit. In reviewing claims with GIP, respite or continuous home care hours billed there are several possible review results. A claim may be paid in full as billed, denied in full, or paid at a reduced rate. For example, a claim billed with GIP days may be paid at the routine care rate. When a claim is denied or reduced to routine care days by Palmetto GBA, the reviewer has indicated, based on the documentation submitted, the level of care billed does not appear to be reasonable and necessary. Palmetto GBA makes a review determination based on the documentation submitted and the provider is held liable for those charges. If the provider feels the level of care is warranted the redetermination process is an option. 35) Can you provide guidance on what constitutes volunteer hours? Volunteer hours give the family or caregivers a break (i.e. to run errands). Neither the regulations nor the Conditions of Participation (COP) provide a definition of volunteer hours. This question should be provided by the Coalition to CMS or to their state officials to receive a specific definition. 36) We are looking for clarification for the Special Reminder on the MLN Matters #MM5567/CMS Transmittal #1372: "The site of service code Q5003 is to be used for skilled nursing facility residents in a non Medicare covered stay, while Q5004 is to be used for skilled facility residents in a Medicare covered stay."
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a) Is Q5003 used in instances when a patient receives Medicare covered Hospice care in a Nursing Home that is not Medicare certified? No. The Q5003 is to be used in instances where a beneficiary is admitted to a Skilled Nursing Facility (SNF) for a stay that would not be covered by Medicare for services unrelated to the terminal illness. b) Is Q5004 used when a patient receives Medicare covered Hospice care in a nursing home that is Medicare certified? No. The Q5004 is to be used in instances where a beneficiary is admitted to a SNF for a stay that would be covered by Medicare for services unrelated to the terminal illness. c) And/or does Q5004 relate to a situation where the patient is in a Medicare certified SNF and the SNF is billing Medicare A for a condition not related to the terminal illness and the Hospice is billing T-18 simultaneously for Hospice care for the terminal illness. Please provide clarification on T-18. 37) It seems to be taking longer for Palmetto to process 855As. One hospice agency submitted an 855A in August 2007 when it moved to a new address. They have been calling the provider line weekly since then, but no one can tell them how long it will take to get it processed. In the meantime, all of their Medicare checks have been returned and voided since October, causing major cash flow problems. Another hospice submitted 855As for two new locations in September 2007. This hospice is in a CON state, and these locations were established to serve rural areas that the State determined were underserved. They have also called the provider line numerous times but can get no answer as to the status of those requests. At one point Palmetto referred them to CMS who in turn referred them back to Palmetto. In the meantime, they are not able to bill at all, which is causing significant financial losses. Why is it taking so long to process 855As, and how long should it normally take? Is there a contact person hospices can call directly to find out the status of their 855As if they cannot get information through the provider line? For several years, large increases in enrollment workload volume have been experienced in both home health and hospice, far in excess of budgeted staffing levels. The effect of these increases hit especially hard during the last six months, particularly with the growth driven by several states. Palmetto GBA recognizes that increased processing times pose difficulties for providers and has been actively working to reduce inventory levels and improve processing time. Recently, increased enrollment funding was received from CMS and we have been adding enrollment resources. We are also working on automation efforts to improve processing.
Hospice Coalition Q & A
16
Prior to the issues contributing to the longer processing times, Palmetto GBA processed 80% of applications within 60 days and 99% within 180 days. The actions herein described are designed to return us to that level, but given the amount of inventory and continued increase in receipts it will take some time. We will strive to process as quickly as possible and hospices that need information or assistance regarding a particular application may contact either Charlene Craven at 803-763-5372 or via email at
[email protected] or Teresa Newton at 803-763-5548 or via email at
[email protected]. Teresa returns to the office Monday, February 18, 2008. 38) Can you provide an update as to Palmetto GBAs educational plans for 2008? A number of hospices have asked if Palmetto would be resuming the 2 day symposiums in the near future. The 2008 Home Health and Hospice Workshop series kicked off in January in Louisiana. Due to the high demand from providers we have once again partnered with State Associations to speak at their conferences and Palmetto GBA will be sponsoring workshops in several states. The workshop schedules and contact information regarding registration and locations are posted on the Palmetto GBA Web Site at http://www.palmettogba.com/palmetto/providers.nsf/44197232fa851689852571 96006939dd/85256d580043e754852573e50074ed74?OpenDocument At this time no symposiums are scheduled. Please see Attachment C 39) What are Palmetto’s plans to improve service to providers so we can receive more timely and complete answers to our questions? The new provider 800 number procedure is not working. Now providers can only leave a message and hope someone calls them back – there is no way to talk to a real person. When and if someone does call back, that person rarely has an answer, then the provider has to wait for someone else to call with the answer. If someone does call back, it’s generally a different person who may or may not have understood the original question. And if no one ever calls back, the provider has to start all over with a new person on the 800 line because you can’t ever get back to the same person. In addition, when it comes to dealing with billing issues, we are finding that the customer claims representatives do not give you an answer without consulting the Medicare billing manual or having to escalate to another tier level person for an answer. All these processes can take days or weeks to finally get an answer (if ever); this is very frustrating for providers. We want to do things right, but we can’t get timely answers with this new system. We would like for Palmetto to consider going back to having provider relations representatives we can contact directly with questions or problems or some other system that at least allows us to get back in touch with the same person we’ve been dealing with on an issue.
Hospice Coalition Q & A
17
The SC Part A PCC contact number is 866-801-5301. This number is routed through our IVR. There are a series of options available including speaking to a live associate. Presently our IVR does not present an option for voice mail. Providers receive call backs when either one is requested or the customer service representative states they will receive a call back. Palmetto GBA adheres to the answering telephone inquiries in accordance with IOM Pub 10009 Chapter 6. This process requires a complex inquiry be answered by a more experienced associate; and may require a call back when a Level 2 Associate is not available. We encourage our associates to use Manual References in our responses to promote provider education, clarity and consistency for all updates and questions concerning billing issues. If the call is escalated to a Level II or Level III, these associates have a maximum of 10 business days to call the provider back with the answer. Palmetto GBA’s Provider Contact Center has taken several actions to continue our focus on quality service and performance: Staffing and Development/Reporting/Quality Assurance • Allotted 8 hours per month for associate training including targeted training on the top 20 types of calls. •
Utilize a dedicated workgroup to review CMS Changes and promote discussion regarding new and updated policy changes.
•
Perform data analysis using both our internal tracking system as well as coordinated feedback from our Provider Outreach and Education department.
•
Proactively assess workload management to ensure timely and accurate responses
•
Active internal Quality Assurance program that performs random audits on telephone and written inquiries monthly.
•
Our Quality Program measures both knowledge base and accuracy level. Current performance as of December 31, 2007 : Knowledge = 90% Accuracy = 90%
•
Questions or Concerns about the PCC should be directed to Thomas Stallworth at
[email protected].
Data Analysis Link: http://www.palmettogba.com/palmetto/providers.nsf/$$ViewTemplate+for+Doc s?ReadForm&Providers/Part+A+Intermediary/North+Carolina+Part+A+Interme diary/Learning+&+Education/Claims+Submission+Error+Help
Hospice Coalition Q & A
18
40) What is the status of the MedPAC review of the hospice reimbursement system? Are there any changes being considered and if so, what is the anticipated timeframe? Currently there is no information on the status of the MedPAC review. 41) We have had situations where we have started care on a patient, the patient and/or family does not tell us the patient was on hospice before, the other hospice has not entered their NOE. We start the patient in their 1st benefit period, bill our claims and get paid, then the first hospice calls (sometimes over a year later), asks us to back out our claims in order for them to bill the days they had this patient prior to us because of sequential billing. The hospice which had to back out their claims will now go past the timely filing date, will Palmetto go back and pay second hospice? Medicare systems should process and pay any claims resubmitted by a hospice in a situation where the hospice cancelled their claims due to another provider needing to submit claims for sequential billing purposes. In the event of a timely filing edit occurs, the hospice should contact the Provider Contact Center (PCC) and request that the claims be processed for payment. 42) Will hospices be required to start using taxonomy codes on their claims? Currently, hospices are not required to report taxonomy codes on their claims. Effective January 1, 2007, institutional Medicare providers who submit claims for their primary facility and its subparts (such as psychiatric unit, rehabilitation unit, etc.) must report a taxonomy code on all claims submitted to their FI. No further instructions regarding the use of the taxonomy code have been received regarding other types of providers. 43) Please provide us with an update on the MAC process. Neal Burkhead will provide this update during the meeting. 44) Recently a hospital received a letter from a HMO which stated the following: HMO does not pay for any services rendered by the hospice provider nor for care directly related to the terminal condition. HMO does not pay for other care that is not related to the terminal condition while the member is in a hospice election. These charges must be filed to the Original Medicare for reimbursement. Can Palmetto GBA provide clarification and direction on how hospice payment works with a HMO and how nonrelated care works with the HMO? Medicare beneficiaries enrolled in managed care plans may elect hospice benefits. Federal regulations require that the regional home health intermediaries (RHHIs) maintain payment responsibility for hospice services and for other claims the RHHI may pay as a regular servicing fiscal intermediary (FI) for managed care enrollees who elect hospice; specifically regulations at 42 CFR 417, Subpart P, 42 CFR 417.585 Special Rules: Hospice
Hospice Coalition Q & A
19
Care (b), and 42 CFR 417.531 Hospice Care Services (b). FI claims for services not related to the terminal illness would otherwise be the responsibility of another FI. Managed care enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked. As specified above, by regulation, the duration of payment responsibility by feefor-service contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiaries.
Hospice Coalition Q & A
20
PCA Decision Tree Provider Specific Probe Review (20-40 claim sample) Service Specific Probe Review (100 claim sample)
Data Analysis
16-50% *CDR
C 51-100% *CDR
Review resumes for provider - Phase II, Qtr 1
A
B
0-9% *CDR
10-15% *CDR
Written Corrective Action Plan (CAP) requested from provider
End of Qtr 1 CDR calculated
A Medical review discontinued
Remove from medical review, education provided, possible reprobe in 6 months
B
16-50% *CDR
C
Review resumes for provider - Phase II, Qtr 2
After prolonged review with little or no improvement
End of Qtr 2 CDR calculated
Charge Denial Rate (CDR) A
B
16-50% *CDR
Charges Reviewed *CDR = Written Corrective Action Plan (CAP) requested from provider Revision - #1 Revised 01-23-07 MR-QSF-7.5.1 POE - PCA Decision Tree
C
ATTACHMENT A
Charges Review and Denied ____________________X 100
-Referral for program exclusion, suspension of payment, or civil monetary penalty -Referral to the Payment Safeguard Contractor (PSC) -Postpayment Comprehensive Medical Review -Withhold payments
ATTACHMENT B
Palmetto GBA 2006 Hospice Cap Overpayments by State As of 2/1/08 Item Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
State Code 1 3 4 5 6 7 8 10 11 14 15 16 17 18 19 22 23 24 25 26 28 29 31 32 33 34 36 37 39 42 44 45 46 49 51 52
TOTAL
State Alabama Arizona Arkansas California Colorada New Jersey Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania South Carolina Tennessee Texas Utah Virginia West Virginia Wisconsin
Total Providers 90 7 25 12 1 2 2 38 78 56 46 1 1 18 81 6 3 2 85 9 3 1 5 33 1 64 66 112 12 47 43 190 2 10 1 2
1,155
Completed With O/P 81 40 5 3 20 0 11 0 1 0 2 0 2 0 38 4 68 8 53 3 39 1 0 0 0 0 6 0 41 5 1 0 3 0 1 0 54 32 2 0 0 0 1 0 5 1 15 3 0 0 38 5 35 1 48 16 8 0 24 4 24 0 91 6 2 1 2 0 0 0 1 0
722
133
% completed with O/P 49% 60% 0% 0% 0% 0% 0% 11% 12% 6% 3% 0% 0% 0% 12% 0% 0% 0% 59% 0% 0% 0% 20% 20% 0% 13% 3% 33% 0% 17% 0% 7% 50% 0% 0% 0%
O/P Amount ($43,325,818) ($6,134,952)
($4,259,877) ($3,220,319) ($411,247) ($407,990)
($823,046)
($32,492,605)
($260,168) ($2,733,168) ($13,026,685) ($1,538,414) ($7,563,945) ($1,581,693) ($4,006,168) ($147,086)
($121,933,181)
ATTACHMENT C
How to Access the 2008 Hospice Workshop Schedule To access the 2008 Hospice Workshop Schedule: 1. Go to www.PalmettoGBA.com/rhhi 2. Select the Hospice link under the Articles and Medical Policies section 3. Scroll down to Score a Touchdown with Medicare: 2008 Hospice Workshop Schedule!
article and select the link
Hospice Reversal Rate
Totals by State
First Quarter 2008
Redeterminations
State Quarter Total Redetermination Cases
Oct
Nov
Autodeny
Percent
Dec
Affirmed
Dismissed
QIC Reversed
Affirmed
ALJ
Dismissed
Reversed
Affirmed
Dismissed
Reversed
AL
5
164
24
110
16
0
4
1
0
1
AR
0
10
1
3
1
0
0
0
0
0
278
218
231
727
54%
FL
2
111
5
61
39
0
1
3
1
12
44
23
22
89
7%
GA
1
15
7
27
1
0
2
0
0
0
Reversed (Partial or Complete)
217
169
138
524
39%
IL
0
53
2
25
6
0
1
1
0
1
Total Cases
539
410
391
1340
Affirmed Dismissed
QIC Cases
Dismissed Reversed (Partial or Complete) Total Cases
ALJ Cases Affirmed Dismissed
1
11
2
9
1
0
0
0
0
0
2
13
0
11
2
0
2
0
0
2
LA
0
32
1
20
3
0
0
0
1
0
40
70
114
224
82%
MS
0
33
13
24
13
1
4
0
0
6
1
0
10
11
4%
NC
0
31
0
24
25
0
5
0
0
0
9
15
15
39
14%
NM
0
21
0
3
23
0
1
2
1
5
50
85
139
274
OH
0
7
0
3
1
0
5
0
0
0
Oct
Affirmed
IN KY
Nov
Oct
Dec
Nov 16
OK
6
39
9
26
15
0
1
1
0
0
SC
4
9
5
9
2
0
1
2
0
2
32%
TN
2
6
4
7
6
0
0
0
0
0
TX
14
60
14
76
37
9
7
11
0
11
Dec 8
2
26
2
0
6
8
10%
Reversed (Partial or Complete)
23
13
12
48
59%
Total Cases
41
21
20
82
ATTACHMENT D
