Hospice Coalition Questions and Answers: June 20, 2024

Published 07/15/2024

To: Hospice Coalition Members

From: Palmetto GBA Provider Outreach and Education (POE)
Date: June 20, 2024

Reports

Questions for Response

Medical Review

1. A hospice had denials in Round 1 of Targeted Probe and Educate (TPE) due to the election statement missing the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) contact information. The hospice progressed to Round 2 of TPE. Palmetto GBA is requesting records for patients admitted prior to the Round 1 audit which means those election statements will be deemed invalid. Likely, this will cause the hospice to fail Round 2. The purpose of the TPE is supposed to educate and then allow time for the hospice to implement corrections so they can demonstrate their improvement in the next round. Palmetto GBA’s review process does not allow a hospice to demonstrate its improvement which seems unfair to the hospice and is contrary to the intended purpose of the TPE.

 

a. Question: Can Palmetto GBA reset edit parameters to avoid these situations of auditing patients admitted prior to Round 1 so that hospices are not destined to fail a second round?

 

Answer: Edits cannot be set to exclude patients as the audits are provider-specific and the sequel claims would not be excluded by any other review contractor’s audits. Claims requesting payment should not continue to be submitted once a provider is aware the requirements of the election were not met.

In prepay TPE audits, a hospice would be allotted time to correct deficiencies. For example, the hospice may determine to complete an administrative discharge, continuing care of the beneficiary until all reelection requirements are met. From the time the error is finalized in claim processing and the letter notifying of the claim denial is issued, to the start of an additional round of TPE, would be at minimum 45–56 days from after the end of round education occurs.

This timeframe does not include additional time needed for MAC end of round calculations, development and issuing of the provider’s round result letter or the time between the provider receiving the results and scheduling of the end of round education. Please note we will not delay the scheduling of the education. (Resource: Targeted Probe and Educate.)

 

b. Question: Another concern is that Additional Documentation Requests (ADRs) are being received for patients who were reviewed and denied due to the election statement in Round 1. This means the subsequent claim will be denied. Can Palmetto GBA exclude in Round 2 any claims for patients denied in Round 1?

 

Answer: Edits cannot be set to exclude patients as the audits are provider-specific.
 

 

2. Question: We are in Round 2 of a TPE for routine home care (RHC). We are seeing many of the ADRs being for patients with long length of stay (LOS). Twenty records were requested from over 2,200 claims billed in a month, and 40 percent of the charts requested were for longer lengths of stay. We do not have 40 percent of our census as long-stay. Is Palmetto GBA now including long LOS claims in routine TPE audits?

 

Answer: The edit parameters have not changed for RHC. Claims are randomly selected as billed for the audit.


3. Question: Please provide information on what is being reviewed in the Low General Inpatient Care (GIP) Utilization Probe and Education Review. We received notice that a Low Utilization Probe and Education (LUPE) review was initiated to probe a sample of our claims billed for Hospice GIP Low Utilization. We received ADRs but before we submitted records, we received a notice that we had been removed from the LUPE review process. What is the purpose of the review? Was there some type of automated review of claims conducted without an accompanying review of medical records?

 

Answer: The Low Biller Probe & Educate review was a pilot conducted like TPE. This review was aimed at identifying outlier providers who bill at a lower frequency. The Low Biller Probe & Educate pilot was initiated to review a maximum of five claims. Palmetto GBA removed providers where billing ceased or was minimal after identification. Removed providers are monitored for the inclusion on a potential TPE edit, referral (education, UPIC, RAC) depending on findings.


4. Question: Our hospice is in a TPE review. We received 19 ADRs initially and submitted records for review. We have not had a request for any additional charts in several months. Why is it taking so long for more claims to be pulled? Is there a defined period over which the audit can continue?

 

Answer: The timeframe has not changed for TPE as discussed in previous sessions. Claims are selected at random and may take longer for prepayment edits as providers are reprioritized. Reprioritization occurs based on internal analysis or request (CMS, UPIC, etc.). The only claims under a TPE audit are those sent an ADR. If there are any concerns related to the timeframe between claim selection, please contact the Palmetto GBA contact center related to your concern. If Palmetto GBA can accommodate a reprioritization, we will make efforts to select additional claims.


5. Question: Palmetto GBA has issued claim denials during TPE related to the date that the addendum is delivered to the patient. The situation is that a patient signed the election statement prior to hospice admission, which regulations allow, and requested the addendum at that time. But the patient was hospitalized on that date and the hospice could not yet produce an addendum because the comprehensive assessment could not be completed, and the coverage of medications was not known. The regulation at 418.24(d) addresses timing and can be confusing. 

 

In the commentary of the FY 2022 Hospice Payment Final Rule (PDF), CMS made it clear that the comprehensive assessment needed to be completed before a hospice could determine what is related. CMS stated, “If the addendum is completed prior to the comprehensive assessment, the hospice may not have a complete patient profile, which could potentially result in the hospice incorrectly anticipating the extent of covered and non-covered services and lead to an inaccurate election statement addendum. Hospice providers are only able to discern what items, services, and drugs they will not cover once they have a beneficiary’s comprehensive assessment.”

 

Based on that CMS commentary, we think that the clock could not start ticking until admission takes place and the comprehensive assessment is completed, and our claims were wrongly denied. If Palmetto GBA continues to disagree with the timing and will deny claims if the addendum is not delivered within five days of the request regardless of the election date, will you ask CMS for clarification on the timing of the addendum delivery in a situation where the addendum is requested prior to admission and completion of the comprehensive assessment?

 

Answer: Palmetto GBA’s interpretation is that if the patient (or representative) requests the addendum at election, it must be delivered within five days of the admission to hospice. If the election statement was signed prior to admission, then the addendum must be delivered within five days of admission which may not be within five days of the signed election. In other words. the admission to hospice is the “effective dates of election” and the timeline for the delivery of the addendum would be calculated accordingly. This is supported by the FY 2022 Hospice Payment Final rule.

 

The current regulations at § 418.24(c) require that if a beneficiary or his or her representative requests the addendum at the time of the initial hospice election (that is, at the time of admission to hospice), the hospice must provide this information, in writing.

Comprehensive Error Rate Testing (CERT)

6. We have recently received a Comprehensive Error Rate Testing (CERT) request for a claim that was already requested from Palmetto GBA for the GIP TPE. When we reached out to the CERT contractor contact, we were informed that although it was already requested by Palmetto GBA, we needed to submit the chart for their review as well. If Palmetto GBA can offer some clarity on this issue, it would be appreciated.

 

a. Question: Our understanding is that once a specific claim is requested for review, another requestor cannot request that same claim. Is that accurate?

 

Answer: The CERT contractor chooses a random sampling of processed claims from each MAC, requests medical records and reviews them to determine if an error in payment was made. The samples include claims that were both paid and denied by the MAC. After the claims within a specific period are reviewed, an improper payment rate is determined for each MAC. (Resource: Chapter 3, Section 3.5.2 — Case Selection of the Medicare Program Integrity Manual [PDF]. CERT shall duplicate another contractor’s review, when appropriate, if those claims are chosen as part of a statistically valid random sample to measure the improper payment rate.)
 

b. Question: What would a provider do if two different determinations were made for a specific claim?

 

Answer: If the CERT contractor finds a claim in error after a MAC review determines the claim is payable, the claim will be adjusted based on CERT’s review decision. The provider may appeal the CERT Contractor’s review decision to Palmetto GBA.

 

c. Question: How would the provider follow up in the levels of appeal?

 

Answer: Follow the normal redetermination process to appeal all CERT denials. Providers are encouraged to use the optional CERT redetermination form which is available on the Palmetto GBA website (JJ Part A, JJ Part B, JM Part A, JM Part B, Railroad Medicare, Home Health, and Hospice) and through eServices.

Provider Enrollment

7. Question: How long does a change of address application take to process? Are there actions outside of Palmetto GBA’s functions in the process that could delay it? Does the State Agency or CMS have to approve it? Is a site survey needed? If the Application Status Lookup Tool indicates the document was completed more than a month ago and no written confirmation has been received, what action should a provider take?

 

Answer: Paper Applications with additional development, require fingerprinting or a site visit has a 65 to 100 day processing timeframe (this is contingent upon provider submitted required development and/or responsiveness to fingerprint); Applications with no development, fingerprint or site visit has a processing timeframe of 30 days. Fingerprinting and site visits timeframes are outside of a MAC’s control and timeframes may vary by state. The State Agency or CMS will need to approve a change of address and a site survey needed once state approval is received.

 

If the Application Status Lookup Tool indicates the document was completed more than a month ago and no written confirmation has been received, please contact the PCC at 1.855.696.0705, press/say 2 or Provider Enrollment for a Provider Enrollment Representative. (Resource: Palmetto GBA IVR HHH/Part A Call Flows, PDF.)

Claim Processing

8. Question: MLN Matters Number MM13531, Hospice Claims Edits for Certifying Physicians, states that although the PECOS enrollment requirement is effective June 3, 2024, claim edits will not occur until October 7, 2024, and later submission dates. Does that apply only to the later edit that will trigger for both the ATT PHYS NPI and the REF PHYS NPI? Will the MACs retroactively review or reprocess claims for date of service June 3, 2024, forward submitted prior to October 7, 2024?

 

Answer: Claims, including adjustments, submitted on or after October 7, 2024, would need to follow MLN Matters Number MM13531’s direction. The MACs will not retroactively review or reprocess claims received prior to October 7, 2024. An adjustment may be submitted for certifying physician edit 17729 when an input error (e.g., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. For more about adjustment of reason code denials of 17729, please see Reason Code 17729.

 

9. With the latest updates and Q&A document for the certifying physician edits, we have questions about how we will be paid for physician visits completed by our employed NPs from June 3, 2024, to October 6, 2024, if they are not reported as the attending physician. The Q&A dated May 14, 2024, which supports MLN MM13531, state, “For claims submitted from June 3 through October 6, if an NP is listed in the Attending Physician field, the claim will deny.” The guidance goes on to say that hospices are not required to report the NP or PA that a patient has designated as their attending physician on hospice recertification claims from June 3, 2024, to October 6, 2024. We are supposed to report the certifying physician in the Attending Physician field and the NP or PA “in the Other/Referring Physician field (if the hospice chooses to populate it).”

 

a. Question: Per the guidance, the attending nurse practitioner would not be identified on the claim. Will there be any issue with the hospice being reimbursed for medically necessary billable visits by a hospice-employed NP? Similarly, when the attending is a community NP, will there be any issues with reimbursement to the community NP if the NP is not identified on the claim?

 

Answer: No, the processing system(s) do not edit for this and the line items for medically necessary physician services do not include the physician/NP/PA’s National Provider Identifier (NPI). For TPE, the documentation would support the physician/NP/PA’s medically necessary billable service billing on the hospice. 

 

Excerpt from the FAQ on May 14th on how to manage the NP: "For claims submitted from June 3 through October 6, if an NP or PA is listed in the Attending Physician field, the claim will be denied regardless of whether occurrence code 27 is used. Beginning October 7, the edit will bypass the NP or PA."

 

Hospices are not required to report the NP or PA that a patient has designated as their attending physician on hospice recertification claims from June 3 through October 6. For such claims, the certifying physician would be reported in the Attending Physician field and the NP or PA in the Other/Referring Physician field (if the hospice chooses to populate it). If not, leave the Other/Referring Physician field blank.

 

For recertification claims submitted on or after October 7 with dates of service June 3, 2024, or later, if the patient’s designated attending is a NP or PA, enter the NP or PA in the Attending Physician and the certifying physician in the Other/Referring Physician field. The edit will bypass the NP or PA and check the Other/Referring Physician field for the certifying physician. This is the only billing change beginning October 7.
 

 

10. Question: We have a hospice physician who has been working on his PECOS enrollment for months. Initially, our legal counsel had to submit a letter to CMS to confirm that the physician was authorized to be associated with our provider number. Then the physician was advised that we must accept him as a provider in PECOS. We do not understand what is needed because he is already listed as a provider for our agency. We need to submit claims with his NPI as the certifying physician, but until this is corrected, we must complete manual overrides in the EMR to ensure we do not have held claims. Does Palmetto GBA have any advice or recommendations about how to resolve this and other similar issues related to the PECOS enrollment processes?

 

Answer: This does not seem like a Part B enrollment issue for the new certifying physician edit with the information provided or it is a combination of two separate enrollment requirements. The new claim edit does not require the physician’s PECOS enrollment to be associated with a hospice.

 

It may be related to the new requirement in Change Request 13333 and the clarification of 42 CFR § 424.502 requires hospices to report the administrator and medical director of a hospice as an “Managing Employee” in Section 6 of the hospice’s CMS-855A application. This requirement has an effective date of January 1, 2024. The agency will need to complete a change of information CMS 855A to report the administrator and medical director of a hospice as an “Managing Employee” in Section 6 of the CMS-855A application.

 

Resources

11. Question: Please provide clarification regarding the following scenario: A patient experienced stroke-like symptoms and his wife wanted him evaluated in the emergency department. The hospice nurse visited and contacted EMS to provide transportation. The ED contracted with our hospice was on diversion for incoming traffic and the patient had to go to a non-contracted facility. We discharged the patient as being out of our service area based on the guidance in the Medicare Benefit Policy Manual, Chapter 9, Section 20. This practice has been questioned by someone else in our organization. Is discharge for leaving the service area the correct option and acceptable in this situation? Is there another choice that we should have made? If so, where is that guidance?

 

Answer: Out of hospice service area discharges may be applied for patients who are admitted to a hospital or SNF that does not have contractual arrangements with the hospice, not outpatient or ED visits.

 

Medicare Benefit Policy Manual, Chapter 9, Section 20, also states “in a facility” and in this example, Medicare’s expectation is that the hospice provider would consider the amount of time the patient is in that facility and the effect on the plan of care before making a determination that discharging the patient from the hospice is appropriate. (Resource: 30.3 — Data Required on the Institutional Claim to A/B MAC (HHH), Condition Code Section of the Medicare Claims Processing Manual, PDF.)


 

12. Question: We have a patient who has a Humana Medicare Advantage (MA) plan but who is currently covered under Medicare fee-for-service due to electing the Medicare Hospice Benefit. The patient sees a dermatologist for skin lesions unrelated to the hospice diagnoses, so the physician is billing traditional Medicare as required, but then they are billing the patient for copays stating they cannot bill Humana for the copays because of hospice election. Patients with MA plans do not have Medicare supplemental plans.

 

a. Question: Is the MA plan not responsible for covering the copays? Can the dermatologist bill the MA plan as secondary? It would be unfair for the patient to have to pay out-of-pocket for copays that normally would be covered by the MA plan. If the patient has no coverage for the copays, then they are penalized for electing the hospice benefit.

 

Answer: This is a MA question and Palmetto GBA does not oversee MA requirements or regulations. The MA plan would need to be contacted on what they would provide in benefits, if any, after a hospice election.

 

After an election by MA enrollee, Original Medicare pays the hospice for hospice services and pays for services of the managed care attending physician, who may be a nurse practitioner, (as defined in section 20.1 of this chapter) and services not related to the patient’s terminal illness, through the fee-for-service system. Since Original Medicare pays for services not related to the patient’s terminal illness, a copay (if applicable) would be assigned to the service. (Resource: Medicare Benefit Policy Manual (PDF), 20.4 — Election by Managed Care Enrollees.)

 

b. Question: Does Palmetto GBA have guidance on this?

 

Answer: See above.

General

13. Question: In the latest Model Election Statement that CMS posted (March 2024), under the section titled “Right to choose an attending physician” the beneficiary is given information regarding their right to choose or not choose an attending physician. This section also asks the beneficiary to “please provide any information that will uniquely identify your attending physician choice.” On the form there is no indication or information given to the family about what “uniquely identifying” information is except to provide the “Physician Full Name.” Typically, it would be abnormal for the patient to have information that would “uniquely identify” the Physician other than their name. Does a hospice not need to enter the NPI or other identifying information or is only a name needed?

 

Answer: Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician, nurse practitioner (NP), or physician assistant (PA) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician. An NPI may be obtained from the NPPES NPI Registry using different identifiers of the physician, NP, or PA such as first and last name, city, and state. (Resource: Medicare Benefit Policy Manual (PDF), Section 20.2.1 — Hospice Election.)

Provider Contact Center (PCC)

14. Question: What resolution steps are available to providers when a claim is rejected or recouped in error for VBID? Is there a contact at the MAC that we can escalate these issues to? We called Provider Services and were advised to submit an 817 with remarks that fee-for-service Medicare is responsible since the patient’s hospice admission occurred prior to the VBID plan’s participation in the model, but these claims all rejected again for the same reason. We have escalated to CMS VBID who agree fee-for-service Medicare is responsible for payment and state they forwarded the issue to the MAC. Upon follow up, CMS is now advising us to also follow up with the MAC. What steps do we take to get resolution so our claim can be paid?

 

Answer: A new Claims Payment Issues Log (CPIL) for VBID processing issues is being posted currently (may be posted by June 20, 2024). CMS is aware if this issue. Please see the “Provider Action” from the CPIL below.

 

“No provider action is needed. If a Medicare VBID claim was processed and paid or rejected incorrectly prior to April 1, 2024, the hospice may attempt an adjustment to receive the proper outcome. Palmetto GBA will provide updates as soon as they are available.

 

To help hospices determine who is the payer in VBID, CMS has developed the CY 2024 VBID-Hospice Supplement to Technical and Operational Guidance (PDF). See the coverage scenarios on page 3 and Table 1, Payment Coverage Scenarios, on page 6.”

 

Note: We are getting inquires where hospices are stating Medicare has paid incorrectly for the following scenarios, in which Medicare correctly paid. If a beneficiary elected hospice in 2023 while in a Model-participating PBP, and then the beneficiary enrolls in a non-participating PBP in 2024, Original Medicare would be responsible for the hospice care beginning in 2023. This would be the case as well if the beneficiary’s new PBP was participating in 2023 but ceased participation for 2024. (Resource: Claims Payment Issues Log.)


 

15. Question: Our hospice received a call from 1-800-MEDICARE. They had a Medicare beneficiary on the line who indicated he was having problems accessing needed medical services due to the CWF showing an open record with our hospice dating back to April 2002 – yes, 22 years ago. He stated that he had not received hospice services from us, and we tend to agree because he lives in another part of the country and has not visited our state for medical care. We want to help get his resolved but are getting nowhere when calling Medicare. Our internal systems do not go back that far, and no information is available in the Medicare system to tell us what was billed. All we have is what the 1-800-Medicare representative gave us. She also indicated that this has been reported as fraud but was initially sent to the wrong MAC. This is quite alarming, and we need help to resolve this. We called the Provider Contact Center and the representative said they would escalate this. We did not receive a return call in the timeframe the representative indicated. What can we do to get this resolved, particularly to get the revocation indicator entered so the man can receive needed services and our hospice is not accused of fraud?

 

Answer: To assist with this inquiry, we needed more information that we received on the day of the coalition meeting. Our review found an open election from April 2002 and a claim on the Common Working File (CWF) from May 2002 stating the beneficiary was discharged deceased. A claim patient status of discharge deceased does not add a revocation or termination to a hospice election.

 

This is a complicated inquiry due to its age and is being forwarded to Palmetto GBA’s First Level Screening for investigation. During the investigation and after it is complete, the beneficiary and/or hospice would be contacted and informed of our final determine and actions.


 

16. Question: Please provide information on what providers should expect when calling the Provider Contact Center regarding hold times and timeframes for return calls. Our hospice biller followed up on a question that was more than 30 days outstanding. The representatives at both Tier 1 and Tier 2 said the ticket had not been touched and it would have to be sent back for escalation. The biller asked for a supervisor but after holding for 45 minutes was told no one was available. A representative said that they are overloaded and not able to meet the demands. Does a hospice just have to keep calling back and going through multiple tiers to get resolution? Is there a way to bypass the first tier and go directly to the second-tier representative? We must repeat much of the same information.

 

Answer: We do apologize for any frustration or inconvenience that has been experienced while trying to resolve this issue. Please ensure that provider and beneficiary information is properly authenticated in the Interactive Voice Response (IVR) for proper routing of the call. To assist you with the specific outstanding inquiry, please provide the beneficiary and provider authentication information.
 

Education Topics

 

Next Meeting: October 31, 2024


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