Hospice/MA Carve-in Proposal Earlier today, the Senate Finance Committee’s Chronic Care Work Group (CCWG) released draft legislation, the CHRONIC ACT, to improve outcomes for Medicare patients requiring chronic care. Unlike previous proposals from the CCWG, this legislation does NOT contain hospice/MA Carve-in provisions. The absence of the MA Carve-in can be directly attributed to the advocacy of the hospice community, and the significant concerns about how such a policy proposal would affect end-of-life care.

Committee staff indicated that they hope to move this non-controversial package during the lame- duck session, and that policies not in the most recent draft would likely be revisited in the next Congress. In other words, the MA Carve-in continues to be on the policy horizon for hospice organizations. NHPCO will continue to closely monitor this situation and will continue to advocate for public policies that protect, preserve and promote the Medicare hospice benefit. CAP Overpayment Recoupment Many hospices are currently receiving Notices from your Medicare Administrative Contractor regarding CAP overpayments for the 2015 CAP Year and recalculated overpayments for prior years -- prior year computations are recalculated for three years from the date of the original notice and likely includes 2012-2014. When hospices are notified of a CAP liability, the hospice is provided with fifteen (15) days to make appropriate repayment or request an Extended Repayment Schedule (“ERS”). NGS reports that they have completed their three year look back and providers have been notified. CGS and Palmetto also report CAP overpayment recoupment is continuing. If your hospice receives a Notice of Overpayment, you must act immediately with your plan for either immediate repayment or the request to set up an Extended Repayment Schedule. NAHC Submits Recommendations to CMS, OIG in Wake of Report on Hospice Elections, CTIs October 27, 2016 04:39 PM

In mid-September, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report, “Hospices Should Improve their Election Statements and Certification of Terminal Illness.” In this study the OIG reviewed 563 election statements and related documentation from hospice records that were part of the GIP study; all records were from 2012.

As referenced in previous coverage of the September OIG study, the National Association for Home Care & Hospice (NAHC) has strongly recommended that hospices, relative to their election statements:

 ensure that their election statements specify that the patient is electing the Medicare hospice benefit;

 specify the Medicare coverage waived;  explain the difference between palliative and curative care in the election statement or specifically reference where this explanation can be found in materials presented to the patient prior to election;

 clearly explain the patient’s right to revoke and transfer and the difference between these actions and a discharge in the election statement or specifically reference where this explanation can be found in the materials presented to the patient prior to election.

NAHC has also recommended, relative to certifications of terminal illness (CTIs), that hospices:  ensure the physician narrative of the CTI is completed and includes a summary of the clinical findings that depict the patient’s terminal prognosis (i.e. statement of a diagnosis is not sufficient);

 ensure there is an attestation statement on the CTI and the physician has signed it

One of the concerns referenced by OIG in the report was that insufficient information related to the patient’s waiver of coverage for certain Medicare services was provided on a number of hospice election statements that it reviewed. In a follow up letter toofficials at the Centers for Medicare & Medicaid Services (CMS) and the OIG, NAHC conveyed its support for a “robust admission process that clearly informs the patient and family about the nature of hospice care, provides specific information about the benefit…and directly involves the physician…in determination of eligibility.” However, NAHC also expressed concern that inadequacy of information on some hospice election statements related to the waiver of services may be due, at least in part, to discrepancies between information included in the Medicare Benefit Policy Manual and Medicare regulations. As part of its letter, NAHC urges CMS to clarify language related to its expectations in this regard so that hospices may take appropriate action, if necessary.

The OIG expresses concern about limited physician involvement in determining patient eligibility and points to inadequate/missing physician narrative documents or attestations as indications of insufficient physician involvement. NAHC notes in its letter that hospice narrative and physician attestation requirements must be appropriately met. However, NAHC also expresses concern that the current industry standard for involvement of the physician in determining eligibility generally includes the narrative and attestation, as well as verbal communication or sharing of information that the physician is required to consider in making an eligibility determination. NAHC requests that CMS provide greater detail related to its expectations if they exceed this standard, which is set at 418.25.

NAHC also notes that the OIG makes recommendations related to inclusion of specific items in the election statement that are not currently required by CMS, including a description of the “palliative nature of hospice care.” NAHC points out that many hospices use various materials to convey this information to patients and their family members as inclusion of it in the election statement could make it prohibitively long. Further, the OIG also expresses support for inclusion of other items in the election statement. NAHC recommends that CMS provide clear guidance on what is to be required in the election statement, and strongly supports the OIG’s recommendation that CMS supply model language for use by hospice providers.

In addition to other issues, NAHC references the OIG’s recommendation that CMS enhance surveyor training and require that surveyors review hospice elections statements for accuracy and CTIs for eligibility. NAHC strongly recommends that CMS make clarifications to hospice guidance on the issues noted above prior to expansion of surveyor cuties into this area.

As anticipated, CMS has extended the “Extraordinary Circumstances” due to nursing shortage. The link below will take you to the survey and cert memo announcing the extension. Extraordinary Circumstances due to Nursing Shortage: The period of time has been extended for a hospice agency to elect an exemption to allow for the contracting of nurses pursuant to “extraordinary circumstance” as noted at 42 CFR 418.64 when it believes that the nursing shortage has affected its ability to directly hire sufficient numbers of nurses. • Extension: This policy is effective through September 30, 2018.

Impact of Nursing Shortage on Hospice Care: https://www.cms.gov/Medicare/Provider- Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and- Regions-Items/Survey-and-Cert-Letter-17-01.html? DLPage=1&DLEntries=10&DLSort=3&DLSortDir=descending

Theresa M. Forster

VP for Hospice Policy & Programs

Claims May Not Process with FY2017 CBSA Codes We have a report from some hospice providers that claims that have been submitted with the FY2017 CBSA codes and rates have RTPed. This does not affect all claims submitted with FY2017 rates, but impacts CBSA codes that were updated for FY 2017, after transitioning from the special 50xxx codes used in FY2016. Palmetto has announced that the issue is in research with the FISS maintainer and there is no estimate on when it will be corrected. The full description of the issue is on the Claims Payment Issue Log today. For October claims being prepared for submission, check your MAC’s Claims Payment Issues Log for more information. Palmetto is NOT recommending that providers use the FY 2016 CBSA codes.

CMS Announces Region 1 Unified Program Integrity Contractor CMS has awarded the first Unified Program Integrity Contractor jurisdiction, Midwestern, to AdvanceMed, a wholly owned subsidiary of NCI, Inc. The UPIC statement of work combines and integrates the functions of the former Zone Program Integrity Contractor, Program Safeguard Contractor and Medicaid Integrity Contractor contracts into a single contract. UPIC Midwestern Jurisdiction is scheduled to be fully operational on October 20, 2016.