Hospice Coalition Questions and Answers: October 30, 2024
To: Hospice Coalition Members
From: Palmetto GBA Provider Outreach and Education (POE)
Date: October 31, 2024
Reports
- Attachment A1: Hospice Appeals Report: Quarter 2 (PDF)
- Attachment A2: Hospice Appeals Report: Quarter 3 (PDF)
- Attachment B: Hospice CAP Updates (PDF)
Questions for Response
Medical Review
1. Question: Please give more information on the high-risk audits for hospices in Calif., Ariz., Texas and Nev. We did not receive notice of a Targeted Probe & Educate audit starting.
a. How were providers selected for the audit?
Answer: CMS made the determinations on which hospices were selected for the audit.
b. How many claims will be audited per provider?
Answer: To help reduce burden on compliant providers, initial review volumes will be low. For noncompliant providers, subsequent round reviews may be increased.
c. What do early results show are the main reasons for claim denials?
Answer: It is too early to identify denial trends.
Resource: MLN7215293 — Expanded Prepayment Review of Existing Hospices in Arizona, California, Nevada, & Texas.
2. Question: Per the FY 2025 Hospice Final Rule, the Centers for Medicare & Medicaid Services (CMS) has aligned language in regulations such as 418.22 and 418.25 with language in the Conditions of Participation for the various roles of hospice physicians. With those changes, will medical reviewers accept verbal and written certifications of terminal illness from a hospice physician of any type – medical director, physician designee, or physician member of the hospice interdisciplinary group (IDG), as well as when one is covering for the other?
For instance, the hospice medical director is off today so the team physician gives the verbal certification and completes the written certification in lieu of the medical director. Please confirm that is acceptable.
Answer: Verbal & Written Certifications:
If a verbal certification is obtained from physician A, and physician B signs the written certification if the reviewer can determine both physician A and physician B are hospice physicians, the verbal is acceptable.
Whoever performs the written certification also needs to perform the narrative statement.
3. Question: What is the statute of limitations on contractors having to complete audits? For instance, several hospices in multiple states had Medicaid Integrity Contractor (MIC) audits that were initiated between 2013 and 2016 that were never completed. The audits were at various stages when activity ceased. At what point can the hospice consider the audit terminated and release any monies they had booked from an accounting standpoint?
a. We have heard that the Office of Inspector General (OIG) must complete activity within three years, or a provider does not have to repay any identified overpayments. Is this accurate?
Answer: Palmetto GBA cannot answer this.
b. What about those from the MIC prior to consolidation of Medicare and Medicaid audits under the Unified Program Integrity (UPIC) umbrella?
Answer: Palmetto GBA cannot answer this.
4. What hospice audit topics are on the horizon?
Answer: Two new audits are added. They are:
- Hospice care provided in inpatient hospital
- Respite care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF)
For a complete listing of active medical review audits, please see Jurisdiction M HHH — JM Parts A, B and Home Health and Hospice Active Medical Review List.
Claims
4. Question: We have seen information that many Medicare beneficiaries will receive new Medicare Beneficiary Identifier (MBI) numbers for security reasons. What do hospice providers need to know ahead of this change to ensure their claims will process?
Answer: Hospice Notice of Elections (NOEs) and claims are required to be submitted with the current MBI or they will be returned to the provider for correction. With the five-day requirement to submit NOEs, it is important to verify the MBI is valid. Invalid MBIs submitted on NOEs may cause them to be late and receive a late submission penalty.
Effective May 15, 2023, for NOEs, A/B MAC MACs will not grant exceptions based on MBI changes that were accessible to the hospice more than two weeks prior to the admission date. Only changes that occur shortly before the admission are beyond the hospice’s control.
Hospice billing scenarios when a new MBI is issued.
- The NOE processed under the old MBI. The NOE does not need to be canceled and resubmitted under the new MBI. The hospice needs to enter the new MBI on all future billing on or after the effective date of the new MBI.
- The NOE and monthly claim(s) processed under the old MBI. Everything processed in the Medicare claims system remains — there is no need to cancel the claim(s) or NOE to resubmit them under the new MBI. All billing on or after the effective date of the new MBI must be submitted with the new MBI.
- Claim adjustments must use the current MBI, even if the original claim was submitted with an old MBI
Resource: Home Health and Hospice Billing When a New Medicare Beneficiary Identifier Is Assigned. This article also includes how a provider may verify an MBI is current or terminated using eServices.
5. Question: Please give an update on the claim denial issues that hospices are experienced because of the new claim edit implemented per CR 13531 “Additional Implementation Edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment” implemented on October 7, 2024.
a. Will Palmetto GBA reprocess denied claims? Can providers remove the NPs or PAs from the claims and then file new claims to replace the denied claims?
Answer: CMS and the MACs determines if mass adjustments will occur. Since the October 31, 2024, meeting, it has been determined a mass adjustment will not occur due to most of the claims are billed incorrectly. A mass adjustment would again deny claims that are billed incorrectly.
Hospices can adjust claims and correct the physician fields on the claims using adjustments. Adjustment of non-medical claim denials is allowed in Medicare’s Claim System and providers shall initiate an adjusted claim through their electronic billing software (Direct Data Entry cannot be used).
If a provider’s billing software does not allow adjustments of non-medical claim denials, they should reach out to their vendor. Some hospices have been adjusting physician billing errors denials with 8X7 type of bills and receiving payment.
For more information on hospice reason codes 17729 and 17730 denials, possible resolutions and claim adjustment requirements, please see the article Advance Beneficiary Notice of Noncoverage and Expedited Determination Hospice Guidelines.
b. Will the issues be resolved with the next implementation on November 18, 2024?
Answer: Yes. This implementation streamlines billing on all hospice claims. If there is a designated attending, they are entered in the Attending Physician field. If there is not a designated attending, the hospice certifying physician is entered in the Attending Physician field. The Referring Provider field is only populated when a designated attending is not the medical director of the hospice or the physician member of the hospice IDG.
Resource: Hospice Certifying Physician Billing Instructions
6. Question: Do unrelated ICD-10 diagnosis codes have to be reported on the claim if they do not affect the terminal diagnosis? Is it only diagnoses that are related?
a. For example, should hypothyroidism be reported for a patient on Synthroid even if the hypothyroidism does not impact the terminal diagnosis?
Answer: The principal diagnosis listed on the claim is the diagnosis most contributory to the terminal prognosis. Hospices will report all other diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual effective October 1, 2015. This will also include the reporting of any mental health disorders and conditions that would affect the plan of care.
Non-reportable Principal Diagnosis Codes to be returned to the provider for correction:
- Hospices may not report ICD-9CM v-codes and ICD-10-CM Z-codes as the principal diagnosis on hospice claims.
- Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.
- Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9-CM or ICD-10-CM Coding Guidelines or require further compliance with various ICD-9-CM or ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines.
b. Is Palmetto GBA aware of any analysis of diagnosis data on claims that may influence reimbursement in the future?
Answer: No.
General
7. Question: Why was hospice included in the Emergency Department Services Procedure Codes Billed in Nonemergency Department Sites of Service Comparative Billing Report (CBR) analysis? Hospices bill those ED codes only because Medicare guidelines require that hospice bill consulting physician charges on the hospice claim when related to the terminal illness or related conditions. The hospice compliance and billing staff had significant concerns that they were doing something wrong with their billing. They spent unnecessary time watching the webinar that was referenced in the CBR and then trying to look at coding information online and in their billing systems. Of course, they were relieved to learn that they had not billed incorrectly and were not at risk for audits of these claims. Can hospice bill types be excluded from data analysis that is not relevant to their billing processes to avoid these unnecessary CBRs in the future?
Answer: CBRs are reports that show providers how they rank against their peers in the state and nationally in billing for certain risk areas These reports are educational tools used to assess potential vulnerabilities in the Medicare program by running data. Providers may receive a comparative billing report when they are a statistical outlier in a particular area, which does not mean the provider is doing something incorrectly.
The CBR is not intended to be punitive or sent as an indication of fraud, it is intended to be proactive statements that will help the provider identify potential errors in their billing practice. If providers receive a CBR:
- Evaluate your agency’s billing patterns to ensure the claims are billed accurately.
- Examine the issue identified in the report to see if there are reasons your agency is an outlier in the data
- Evaluate the CPT/HCPCS/ICD-CM codes used related to the issue in the report to verify the most appropriate code is used.
For this CBR, the exclusions were selected by revenue code for Part A claims, not bill types.
8. Question: Please explain the process for overpayment demands because of a Recovery Auditor (RA) or Supplemental Medical Review Contractor (SMRC) audit. A hospice had denials from the RA. They received overpayment demand letters and understood they had 30 days to file an appeal to stop recoupment. Or they could choose to repay the money directly or allow recoupment from future reimbursement. Recoupment would be automatic after 45 days if no action was taken by the hospice. Before the first 30 days had passed, the hospice had a recoupment with a negative payment show on their remittance advice. When they called Palmetto GBA, they were told that this is how it works, and they recoup when the RA tells them to do so. The appeal can be filed, and the hospice will receive its money back if favorable. That is not what the overpayment demand letter states. Why is the money recouped before the deadline?
Answer: The 935 Overpayment and Recoupment Process is used for RA or SMRC determined overpayments. Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments.
Valid redetermination requests must be received by the 30th day from the date of the demand letters to stop recoupment of the 935 overpayments.
Resource: Section 935 Overpayment Recoupment Process.
9. Question: Please explain the process for hospices to be repaid if a claim denial is overturned at the Reconsideration level or the Administrative Law Judge (ALJ) level. Does the Qualified Independent Contractor (QIC), the SMRC, or Office of Medicare Hearings and Appeals (OMHA) provide notice to Palmetto GBA to trigger the repayment?
a. Is there action that hospice should take to facilitate this process?
Answer: No. Once Palmetto GBA or the MAC receives the determination from any of the appeal entities, the claim(s) would be adjusted by that determination and payment issued.
b. Do providers receive interest when recouped monies are returned?
Answer: No. The contractor must pay interest on clean, non-periodic interim payments (PIP) claims for which it does not make payment within the payment ceiling specified in § 80.2.1.1, provided payment is due on such claim.
Interest is not paid on:
- Claims requiring external investigation or development by the provider’s MAC;
- Claims on which no payment is due; or
- Full denials
Resource: Section 80.2.2 — Interest Payment on Clean Non-PIP Claims Not Paid Timely, Medicare Claims Processing Manual (PDF).
10. Question: Hospices are continuing to have issues with physical therapy (PT) and wound care companies providing unapproved services to hospice patients in nursing facilities. When a hospice refuses to pay, the companies bill Part B as unrelated services. Patients and families are told that Medicare will pay for the services, but they receive copay invoices. What action can hospices take to stop this fraudulent behavior? Is this an area that Palmetto GBA can review with data analysis? Hospices continue to receive unwarranted scrutiny from CMS, OIG, and others when they are not at fault in these improper billing situations?
Answer: Anyone suspecting healthcare fraud, waste or abuse is encouraged to report it. Find out how and where to report at Reporting Fraud.
The hospice determines what services are related or unrelated the terminal prognosis of the individual, not the MAC. Hospices must review this information during the hospice election. Hospices may also utilize the Hospice Election Statement Addendum to provide patient notification of diagnoses related to terminal illness and related conditions, for which the hospice would coordinate care.
The MACs that process the PT and wound care claims with the GW modifier would be the entity to determine payment. Data analysis cannot provide a one on one match to make determinations of what would be related or not related.
11. Question: NGS has added Part A Level 2 appeal submissions via their provider portal, NGSConnex. Is Palmetto GBA considering something similar to allow hospices to submit reconsideration appeals to the QICs through eServices? The QIC has online record submission, but no method to track the status of the appeal, print letters, etc. And they will have ALJ decisions as well! Having one location for all appeals to be tracked would be such a blessing. I would like to ask that this be considered.
Answer: eServices does offer submitting Level 2 appeals from the Claims Lookup feature located under the Claims tab for JJ Part A, JM Part A and HHH users. If a Level 1 appeal is found, the status of the appeal will be provided. Multiple links are available for Level 1 Appeals. The links are made available based on the status of the appeal.
Submit a 2nd level Appeal link redirects the user to complete and submit the Level 2 appeal form. The form can only be submitted if the date of submission is less than 186 days from the date the decision letter.
Resource: Page 45 of the eServices User Manual.
Reports
- Please provide an update on the latest quarterly appeals report
- Please give an update on the latest cap overpayments
- Please provide an update on quarterly Service Intensity Add-On Payments and visit utilization
News to Share and Education Topics
- We've Made it Easier to Keep Your eServices Account Active
- Termination of the Hospice Benefit Component of the VBID Model on December 31, 2024
Next Meeting
Virtual on March 6, 2025.