Hospice Regulatory Update

Transcription

1 Hospice Regulatory Update Jennifer Kennedy, MA, BSN, RN, CHC July 2016 National Hospice and Palliative Care Organization Session Objectives Review of the current hospice pertinent topics with detail such as new CMS guidance, survey & certification updates, and quality reporting update. Discuss information about CMS requirements and what issues they are tracking; Discuss scrutiny of hospice claims, provision of care, and on what "hot spots" they are fixing focus. National Hospice and Palliative Care Organization, FY2017 Proposed Hospice Rule Published in Federal Register on Thursday April 28 2% marketbasket increase 2 new quality measures proposed National Hospice and Palliative Care Organization,

2 TRENDS IN HOSPICE UTILIZATION Growth in Patients and Expenditures Patients Served 2000: 513, : 1.4 million Medicare Expenditures 2000: $2.8 Billion 2015: $15.5 Billion Top 5 Diagnoses in 2015 Rank Number of ICD-9 Diagnosis Hospice Code Patients % Alzheimer s disease 195,469 13% Congestive heart failure, unspecified 114,240 8% Lung Cancer 87,661 6% COPD 80,081 5% Senile degeneration of the brain 46,610 3% 2

3 Multiple Diagnoses on Claim Form 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 77.2% % of claims with one diagnosis 72% 67% 49% 37% % of claims with one diagnosis MONITORING FOR HOSPICE PAYMENT REFORM IMPACT Pre-Hospice Spending Five broad categories of hospice patients Alzheimer s, dementia and Parkinson s CVA/Stroke Cancers Chronic kidney disease Heart (CHF and other heart disease) Lung (COPD and pneumonia) All other diagnoses Analysis of pre-hospice spending -- an initial step in determining whether a case-mix adjustment could be created in the future 3

4 Pre-Hospice Spending Diagnosis Mean Lifetime Length of Stay ALL DIAGNOSES 73.9 Alzheimer s, Dementia and Parkinson s CVA/Stroke 55.6 Cancers 47.3 Chronic Kidney Disease 29.8 Heart (CHF and Other Heart 78.8 Disease) Lung (COPD and Pneumonias 69.4 All Other Diagnoses 78.2 Pre-Hospice Spending Analysis $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 180 Days before election 90 days before election 30 days before admission RHC Rate FY2014 $ Leakage CMS believes that it would be unusual and exceptional to see services provided outside of hospice Trend analysis on spending outside the Medicare hospice benefit Non-hospice Part A and Part B spending has decreased by 15.4% Beneficiary cost sharing: $122.5 million in FY2014, down from $132.5 in FY2013 NHPCO provided CMS with an extensive list of recommendations to address leakage 4

5 $710,087,321 $694,130,854 $600,842,732 8/26/2016 Medicare Parts A and B Leakage $720,000,000 $700,000,000 $680,000,000 $660,000,000 $640,000,000 $620,000,000 $600,000,000 $580,000,000 $560,000,000 $540,000,000 Parts A and B Expenditures After Hospice Election "Leakage" Part D Expenditures Outside the Benefit 2014 patient pay amount: $41, comparison: $50.9 million Common Palliative Drugs Analgesics Anti-inflammatory non-narcotic Opioids Antianxiety agents Antiemetics Laxatives 5

6 Cerebral Degeneration Overlapping Drugs - Part D Expenditures $1,880,621 $3,229,221 Common Palliative Drugs $11,563,443 Psychotherapeutic and Neurological Agents Antipsychotics/Antimania c Agents FY2014 Data COPD Part Overlapping Drugs Part D Expenditures $289,214 $195,780 $1,941,201 Common Palliative Drugs Antiasthmatic and Bronchodilator Agents Respiratory Agents - Misc. $8,768,675 Corticosteroids FY2014 Data CMS Concern Hospices are required to cover drugs for the palliation and management of the terminal prognosis We remain concerned that common palliative and other disease-specific drugs for hospice beneficiaries are being covered and paid for through Part D. 6

7 in Millions $334.9 $347.2 $ /26/2016 Part D Expenditures Outside the Hospice Benefit $360.0 $350.0 $340.0 $330.0 $320.0 $310.0 $300.0 $290.0 $280.0 $270.0 $260.0 Part D Expenditures CY2012 FY2013 FY2014 Part D Expenditures Live Discharge Rates All reasons for discharge, including revocation Live discharge rates have declined over time Leveling off at ~ 18% Analysis of hospice live discharge rate amount of non-hospice spending average length of stay incidence of cap overpayments CMS Concern Some hospices may be using the Medicare Hospice program inappropriately as a long-term care ( custodial ) benefit rather than an end of life benefit for terminal beneficiaries 7

8 Live Discharge Rate NHPCO Concerns All types of discharges included Patient revocation is a patient right No way for the individual hospice to respond or correct their practices without additional information % of revocations Reasons for hospice-initiated discharge Use PEPPER report for additional analysis Skilled Visits in the Last Days of Life On any given day during the last 7 days of a hospice election, nearly 47% of the time the patient has not received a skilled nursing or social worker visit On the day of death nearly 26% of beneficiaries did not receive a skilled nursing or social work visit 8

9 Incentives for Skilled Visits Service Intensity Add-on RN and social worker visits Up to 4 hours per day combined disciplines Paid at CHC hourly rate New quality measure measuring visits when death is imminent What is CMS telling us? CMS Data Monitoring Monitoring will include: hospice diagnosis reporting length of stay live discharge patterns and their relationship to the provision of services and the aggregate cap non-hospice spending for Parts A, B and D during a hospice election trends of live discharge at or around day 61 of hospice care, and readmissions after a 60 day lapse since live discharge FY2017 Wage Index Update and Rates 9

10 FY2017 Wage Index Update Proposed marketbasket increase of 2.0% Final market basket for FY2017 May increase or decrease slightly based on updated hospital information Good for planning purposes Official % increase released with final rule in midsummer for October 1, 2016 implementation FY2017 Proposed Rates Level of Care FY2016 National Rate Proposed FY2017 National Rate Routine Home Care 1-60 days $ $ Routine Home Care 61+ days $ $ Service Intensity Add-on Hourly rate $39.37 $40.16 Continuous Home Care Hourly Full 24 hours $39.37 $ $40.16 $ Inpatient Respite $ $ General Inpatient $ $ FY2017 Rates with No Quality Reporting Level of Care FY2016 Payment Rates FY2017 Proposed Payment Rates Routine Home Care (days 1-60) $ $ Routine Home care (days 61+) $ $ Service Intensity Add On $39.37 $39.37 Continuous Home Care Hourly Full 24 hours $39.37 $ $39.37 $ Inpatient Respite $ $ General Inpatient $ $

11 Rate Charts for Your Area NHPCO has created an Excel spreadsheet with every county in the country includes: Proposed wage index for CBSA or rural area Phase in of 2010 US Census complete All levels of care Go to: NHPCO.org/regulatory Hot Topics FY2017 Hospice Wage Index, Payment Rate Update and Hospice Quality Reporting Proposed Rule CAP AMOUNT AND CAP CALCULATION Cap Amount October 1, 2016 and before October 1, 2025 Cap calculation update Same calculation as the hospice payment update percentage Cap amount for 2017: $28, May adjust slightly based on marketbasket update in final rule Cap year for 2017: October 1, 2016 to September 30,

12 Cap Calculations for FY2017 Cap Year Beneficiaries Payments Streamlined Method /28/15 9/27/16 Patient-by- Patient Proportional Method 11/1/15-10/31/16 Streamlined Method 11/1/15-10/31/16 Patient-by- Patient Proportional Method 11/1/15-10/31/ (Transition 9/28/16 11/1/16 11/1/16 11/1/16 Year) 9/30/17 9/30/17 9/30/17 9/30/ /1/17 10/1/17 10/1/17 10/1/17 9/30/18 9/30/18 9/30/18 9/30/18 34 PROPOSED QUALITY MEASURES National Hospice and Palliative Care Organization, Summary of Quality Reporting Section All current measures continue: CMS is not proposing to remove any of the current HQRP measures. Two new quality measures proposed: CMS is proposing changes to the hospice quality reporting program, including 2 new quality measures. Public display and reporting: All 7 current HIS measures will be considered for public reporting Similar to other Medicare provider types CMS Hospice Compare website Spring/summer of CY 2017 National Hospice and Palliative Care Organization,

13 Hospice Visits When Death is Imminent Two measures that assess hospice staff visits to patients and caregivers in the last week of life Measures give flexibility for individualized care in line with patient/family preferences and goals of care National Hospice and Palliative Care Organization, Hospice Visits When Death is Imminent Measure Pair Measure 1 Assesses the percentage of patients receiving at least 1 visit from: registered nurses Physicians nurse practitioners or physician assistants in the last 3 days of life Measure addresses case management and clinical care 1 visit in 3 days Measure 2 Assesses the percentage of patients receiving at least 2 visits from: medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life 2 visits in 7 days National Hospice and Palliative Care Organization, Hospice Visits When Death is Imminent New Items on HIS Discharge Record: 4 new items added to the HIS Discharge record Will collect necessary data Start date for data collection: No earlier than April 1, 2017 National Hospice and Palliative Care Organization,

14 Hospice and Palliative Care Composite Process Measure All 7 current HQRP measures No new data collection will be required; data for the composite measure will come from existing items from the existing 7 HQRP component measures Start date: No earlier than April 1, 2017 National Hospice and Palliative Care Organization, Proposed Enhanced Data Collection Considering new data collection mechanism for use by hospices Hospice patient assessment instrument 1) Provide the quality data necessary for HQRP requirements and the current function of the HIS; and 2) Provide additional clinical data that could inform future payment refinements. In line with other post-acute care settings (e.g. OASIS) National Hospice and Palliative Care Organization, Public Reporting Public reporting via a Hospice Compare website in Spring/Summer CY 2017 All 7 HIS measures Eventual 1 to 5 stars rating Expect that CAHPS will also be included, but no word at this time National Hospice and Palliative Care Organization,

15 Preview Reports Hospices will have time to review and correct their own data Two types of preview reports will be available in CASPER Results for public reporting Provider-level feedback reports (separate from public reporting) for provider viewing only for the internal provider quality improvement National Hospice and Palliative Care Organization, PEPPER REPORTS AS A COMPARATIVE REPORT National Hospice and Palliative Care Organization, Use of PEPPER Reports PEPPER Roadmap to help a provider identify potentially vulnerable or improper payments Assist providers in identifying Free comparative report from CMS contractor Go to Click on PEPPER Distribution Get your PEPPER National Hospice and Palliative Care Organization,

16 Retrieving your PEPPER Report National Hospice and Palliative Care Organization, Hospice Target Areas 2016 PEPPER Live discharges not terminally ill Live discharges revocations Live discharges days Long length of stay Claims with single diagnosis coded CHC in assisted living facility RHC in assisted living facility RHC in nursing facility RHC in skilled nursing facility Episodes with no CHC or GIP National Hospice and Palliative Care Organization, Released November OTHER OFFICE OF INSPECTOR GENERAL ACTIVITY National Hospice and Palliative Care Organization,

17 OIG Releases Guidance for Health Care Governing Boards Guidance updates board responsibility and accountability Ensures that compliance issues are reported to the board Ensures that regular reports are provided from compliance personnel OIG Guidance, "Practical Guidance for Health Care Governing Boards on Compliance Oversight," (April 20, 2015). National Hospice and Palliative Care Organization, Physicians and NPPs Ordering Medications and Supplies NEW Physicians referring/ordering Medicare services and supplies OIG will review select Medicare services, supplies and durable medical equipment (DME) referred/ordered by physicians and non-physician practitioners. Were payments made in accordance with Medicare requirements? (ACA Sec. 6405) Details: CMS requires that physicians and non-physician practitioners who order certain services, supplies and/or DME are required to be Medicareenrolled physicians or nonphysician practitioners and legally eligible to refer/order services, supplies and DME. If the referring/ordering physician or non-physician practitioner is not eligible to order or refer, then Medicare claims should not be paid. Expected issue date: FY2016 National Hospice and Palliative Care Organization, Palliative Care Issues Physician home visits reasonableness of services Prolonged services reasonableness of services The necessity of prolonged services are considered to be rare and unusual National Hospice and Palliative Care Organization,

18 On the OIG Hospice Horizon Hospice general inpatient care Review use of GIP Assess the appropriateness of hospices GIP claims Assess content of election statements for hospice beneficiaries who receive GIP Review hospice medical records to assess appropriateness of level of care NEW! Review beneficiaries plans of care and determine whether they meet key requirements. Determine whether Medicare payments for hospice services were made in accordance with Medicare requirements. Expected issue date: FY 2016 National Hospice and Palliative Care Organization, Future Hospice Issues Future planning efforts for FY 2016 and beyond will include: additional oversight of hospice care oversight of certification surveys hospice-worker licensure requirements National Hospice and Palliative Care Organization, OTHER CURRENT REGULATORY ISSUES National Hospice and Palliative Care Organization,

19 NOE/NOTR SUBMISSIONS National Hospice and Palliative Care Organization, NOE Issues MAC acceptance of NOEs Timeliness Provider liable days -- Hospice not paid for any days prior to the MAC acceptance of NOE Could be 5-30 days of lost revenue Exception requests MAC denial of exception requests MACs report no decrease in the number of exception requests Difficult to gather adequate data for advocacy National Hospice and Palliative Care Organization, Components of Discussion Patient who revokes and returns quickly System cannot track changes Sequential billing Patient transfers from one hospice to another Final claim not submitted from first hospice NOE cannot be submitted timely Keying errors in NOE data submitted 100% accuracy required for payment If not, then CMS database could take up to 3 weeks to find patient National Hospice and Palliative Care Organization,

20 Advocacy Meetings with Congressional and committee staff Meetings with MACs, including possible solutions suggested by MACs to CMS Meetings with CMS Claims Processing Meetings with HHS and OMB Single biggest question: What is the size of the problem? National Hospice and Palliative Care Organization, NHPCO Letter to CMS Developed by NOE/NOTR workgroup of the NHPCO Regulatory Committee Detailed description of problem Recommendations for changes Sent in March 2016 National Hospice and Palliative Care Organization, CMS Letter to NHPCO Working on benefit period issues Looking at options for electronic submission Opportunity for more dialogue Meeting scheduled for continued discussions on options and solutions Very complex issue National Hospice and Palliative Care Organization,

21 HIPAA SECURITY ACTIVITY National Hospice and Palliative Care Organization, Phase 2 OCR HIPAA Audit Program The 2016 Phase 2 OCR HIPAA Audit Program will review the policies and procedures adopted and employed by covered entities and their business associates to meet selected standards and implementation specifications of the Privacy, Security, and Breach Notification Rules Phase 2 OCR HIPAA Audit Program information National Hospice and Palliative Care Organization, When Will the Next Round of Audits Commence? They are already underway! Communications from OCR will be sent via and may be incorrectly classified as spam. If a provider s spam filtering and virus protection are automatically enabled, OCR expects you to check your junk or spam folder for s from OCR; OSOCRAudit@hhs.gov. Click here to view a sample letter. National Hospice and Palliative Care Organization,

22 Who Will Be Audited and How Will They be Chosen? Every covered entity and business associate is eligible for an audit Information from OCR is that 200 hospices will be chosen OCR will not audit entities with an open complaint investigation or that are currently undergoing a compliance review National Hospice and Palliative Care Organization, Common Audit Deficiencies Identified Failure to conduct Security Risk Analysis Lack of training Lack of safeguards for mobile or portable devices Failure to implement encryption Lack of secure transmission ( or text) National Hospice and Palliative Care Organization, Safe Use of Mobile Devices Use encryption Use a password or other user authentication Activate wiping and/or remote disabling for use if lost Enable security software Maintain physical control Use only secure public Wi-Fi networks Delete all PHI when device no longer in use. National Hospice and Palliative Care Organization,

23 Social Media Need defined policies on employees posting PHI on any public site Examples: Yesterday was a hard day! 68 year old admitted to hospice facility with intractable vomiting. Tough seeing her two children in late teens. Then had 37 year old with skin cancer with horrible wound that won t heal. Some days I m not sure why I do this. Thanks for listening. Had a 33 year old female with dx leukemia. Scheduled to sit for caregiver as they have 3 year old, 5 year old and 9 year old with autism so husband could rest. Patient symptomatic. Had multiple transfusions in last month with no success. Having continuous nosebleeds. Children running around. Patient struggled, couldn t get her comfortable. (Details on medications, events, etc.). National Hospice and Palliative Care Organization, MEDICARE WASTE, FRAUD AND ABUSE National Hospice and Palliative Care Organization, False Claims Act Cases and Hospice At least 9 hospice FCA cases initiated or settled in 2015 Settlements combined for approximately $37 million 5 hospices entered into corporate integrity agreements (CIAs) First hospice FCA went to trial in 2015 (AseraCare) Government focusing on whether the documentation supports the physician's clinical judgment Difference of medical opinion does not make the claim a false claim May 2016 Government appealed National Hospice and Palliative Care Organization,

24 Conditions of Payment Found at 42 CFR Distinct from the Conditions of Participation (CoPs) found at through Failure to meet one or more requirements could lead to the denial or repayment of hospice services National Hospice and Palliative Care Organization, To be covered, hospice services must meet the following Reasonable and necessary for the palliation and management of the terminal illness as well as related conditions Individual must elect hospice care in accordance with Plan of care must be established and periodically reviewed by the: attending physician medical director interdisciplinary group of the hospice program as set forth in Plan of care must be established before hospice care is provided Services provided must be consistent with the plan of care Certification that the individual is terminally ill must be completed as set forth in section National Hospice and Palliative Care Organization, New Audit Strategies United Program Integrity Contractors (UPIC) Will combine ZPIC and MIC audit functions Seven vendors competing for the open slots are: AdvanceMed Health Integrity LLC HMS Federal Noridian Healthcare Solutions LLC Safeguard Services LLC StrategicHealthSolutions LLC TriCenturion Inc

25 Highlights in the False Claim Arena Allegations underlying hospice FCA cases remain fairly consistent Eligibility Prognosis or Level of Care Anti-Kickback Violation Deceptive Marketing Admission/Discharge Practices Violation of Conditions of Payment Pressure to Meet Business Targets Beneficiary Inducement Incentive Compensation Falsifying Documents 73 DOJ and HHS ROI Three year return on investment ( ) $7.70 returned for every $1.00 expended $27.8 Billion returned to US Treasury 74 OIG Recoupments First 6 months of FY2016 $554 in audit receivables $2.2 billion in investigative receivables 1,662 individuals and entities excluded from participation in Federal health care entities National Hospice and Palliative Care Organization,

26 New Audit Strategies United Program Integrity Contractors (UPIC) Will combine ZPIC and MIC audit functions Seven vendors competing for the open slots are: AdvanceMed Health Integrity LLC HMS Federal Noridian Healthcare Solutions LLC Safeguard Services LLC StrategicHealthSolutions LLC TriCenturion Inc. National Hospice and Palliative Care Organization, Medicaid Fraud Prevention System Example of new technologies to fight fraud Predictive analytics system, introduced in 2011 Intended to stop improper payments before they are made Reviews 4.5 million Medicaid claims a day Return on investment: $11 recouped for $1 spent National Hospice and Palliative Care Organization, Selection for a Government Audit Complaint Former employee whistleblower Data mining/referral with claims data from the MAC Data mining/referral from PEPPER reports National Hospice and Palliative Care Organization,

27 HIPAA SECURITY ACTIVITY National Hospice and Palliative Care Organization, Enforcement Activity Increased focus on audits, investigations, and corrective action plans Financial costs are large potential fines, expense of corrective action plan, damage to agency reputation OCR will pursue civil monetary penalties for egregious behavior Ongoing review of rule implementation with revised guidance issued as indicated National Hospice and Palliative Care Organization, Complaints to OCR Web portal implemented in July 2013 FY ,000+ complaints FY ,200+ complaints Investigation will be conducted Can lead to fines National Hospice and Palliative Care Organization,

28 Penalties for Rule Violations Civil Monetary Penalties (CMP) $100 to $50,000 or more per violation Calendar year cap is $1.5 million Criminal penalties for knowingly obtaining or disclosing PHI Up to $50,000 fine and up to 1-year imprisonment National Hospice and Palliative Care Organization, Hospice Violation Examples Hospice in Louisiana, Sept. 2014, 700+ individuals 10 encrypted laptops and 1 external hard drive were stolen Laptops contained reports with patient information Hard drive contained bereavement files Able to remotely wipe the laptops Hospice and Palliative Care in Illinois, May 2010, 1000 individuals Employee laptop stolen while on home visit Policy to encrypt and password protect not followed Employee bypassed security National Hospice and Palliative Care Organization, Hospice Violation Examples Hospice in Maryland, Nov. 2013, 7035 individuals Employee ed spreadsheets to personal account which may have been viewed by third party Hospice in Idaho, June 2010, 441 individual Unencrypted laptop stolen $50,000 settlement with OCR 1 st settlement involving less than 500 individuals Corrective Action Plan required National Hospice and Palliative Care Organization,

29 Audit Focus Areas Focus Area Action Breach Notification Encryption and Decryption Workforce Training and Education Policies and Procedures Review breach notification process to ensure compliance with rule. Maintain documentation of breach risk reviews. Record devices that store or transmit ephi. Ensure encryption is in use. Ensure staff education is current. Maintain copies of materials and documentation of attendance. Review privacy, security, and breach notification policies to ensure compliance with current rules. Security Risk Assessment Ensure risk assessment is current and that action plans have been implemented. National Hospice and Palliative Care Organization, Audit Focus Areas Focus Area Guidance Notice of Privacy Practices Review NOPP to ensure it is current and being share appropriately. Review the process for fulfilling requests for individual access Individual Access to PHI to PHI. Ensure implementation of security measures to protect ephi in Data Transmission transit. Business Associates Physical Security Device Safeguards Update list of BAs and ensure agreements are current. Review physical safeguards and ensure functioning locks, alarms, etc. Review policies and processes to ensure correct handling of devices that contain ephi. National Hospice and Palliative Care Organization, Security Risk Assessment (SRA) Key Points Not optional! Must be detailed and written Requires a multidisciplinary team approach Consider using a matrix to guide the assessment Cost of not doing an assessment can be great Can be done in-house by staff or using a outside consultant Must be updated regularly at least annually and with significant changes in equipment or processes National Hospice and Palliative Care Organization,

30 Identify and Document Threats Identify and document reasonably anticipated threats to PHI and EPHI Compile a categorized list of threats Natural, human, environmental Identify different threats unique to the circumstances of their environment Determine likelihood of threats Determine the potential impact of threat occurrence National Hospice and Palliative Care Organization, Common Deficiencies Identified Failure to conduct Security Risk Analysis Lack of training Lack of safeguards for mobile or portable devices Failure to implement encryption Lack of secure transmission ( or text) National Hospice and Palliative Care Organization, Safe Use of Mobile Devices Use encryption Use a password or other user authentication Activate wiping and/or remote disabling for use if lost Enable security software Maintain physical control Use only secure public Wi-Fi networks Delete all PHI when device no longer in use. National Hospice and Palliative Care Organization,

31 Social Media Need defined policies on employees posting PHI on any public site Examples: Yesterday was a hard day! 68 year old admitted to hospice facility with intractable vomiting. Tough seeing her two children in late teens. Then had 37 year old with skin cancer with horrible wound that won t heal. Some days I m not sure why I do this. Thanks for listening. Had a 33 year old female with dx leukemia. Scheduled to sit for caregiver as they have 3 year old, 5 year old and 9 year old with autism so husband could rest. Patient symptomatic. Had multiple transfusions in last month with no success. Having continuous nosebleeds. Children running around. Patient struggled, couldn t get her comfortable. (Details on medications, events, etc.). National Hospice and Palliative Care Organization, National Hospice and Palliative Care Organization, Questions NHPCO members enjoy unlimited access to Regulatory Assistance Feel free to questions to regulatory@nhpco.org National Hospice and Palliative Care Organization,

32 How to keep up NHPCO provider members have access to: NHPCO News Briefs Every Thursday Regulatory and compliance updates every week Regulatory Alerts For time sensitive and important regulatory issues Sign up to receive regulatory alerts Regulatory Round Ups Once a month, all regulatory issues summarized My.NHPCO regulatory entries for specific groups National Hospice and Palliative Care Organization, Regulatory and Compliance Team at NHPCO Jennifer Kennedy, MA, BSN, RN, CHC Senior Director, Regulatory and Quality Judi Lund Person, MPH, CHC Vice President, Regulatory and Compliance us at: regulatory@nhpco.org National Hospice and Palliative Care Organization, NHPCO Regulatory Resources NHPCO website Regulatory check Hot Topics for latest issues Compliance guides, tip sheets, wage index rate charts and detailed regulatory/compliance information Regulatory technical assistance Contact regulatory@nhpco.org National Hospice and Palliative Care Organization,