Public Policy HCA Public Policy No

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1 Public Policy HCA Public Policy No TO: FROM: RE: HCA HOSPICE PROVIDER MEMBERS PATRICK CONOLE, VICE PRESIDENT, FINANCE & MANAGEMENT UPDATES FROM NGS HOSPICE ADVISORY MEETING DATE: JUNE 10, 2016 National Government Services (NGS), New York s Medicare Administrative Contractor (MAC) for Jurisdiction 6 (J6), conducted a Hospice Advisory Meeting yesterday for the state associations in U.S. Centers for Medicare and Medicaid Services (CMS) Regions I, II, V, IX and X. HCA participated in the meeting and received important updates, posed questions and advocated on behalf of our hospice membership. The following memorandum summarizes key updates and/or presentations by NGS staff at the meeting as well as information acquired by HCA on issues of particular importance to New York State, including: ForeSee Survey and NGS Connex Audit and Reimbursement Upcoming 2016 Hospice Education Medical Review and Appeals Data Findings Comprehensive Error Rate Testing (CERT) Information and Data Findings Upcoming Hospice Educational/Clinical Job Aids: Medicare Hospice General Inpatient Level of Care Medicare Hospice Reporting of Influenza, Pneumoccocal and Hepatitis B Vaccines ForeSee Survey and NGS s New Website NGS s Emily Fox-Squairs provided an update on the ForeSee Website Satisfaction Survey which is the survey that appears when one enters the NGS website ( or the NGSConnex website. This survey is utilized by the U.S. Centers for Medicare and Medicaid Services (CMS) to rate each of the Medicare contractors, and it is very important to both CMS and NGS that providers/members complete the survey to tell CMS and NGS what they find helpful/useful on NGS s website as well as what improvements are needed. Ms. Fox-Squairs reviews every completed survey and stated that the overall feedback from home health and hospice providers has been positive with an over 80% satisfaction rate with NGS. Ms. Fox-Squairs then provided an update on NGS Connex which is a free self-service web application that currently offers providers and suppliers access to the following Medicare information: claim status; beneficiary eligibility; provider financial data; provider demographics; an option for submitting cost reports; ability to submit appeal 1

2 requests; and secure messaging. In the next few months, NGS Connex will be updated so that providers will be able to submit Additional Documentation Requests (ADRs) and credit balance reports as well as print remittance advices. NGS Connex can be accessed at: Audit and Reimbursement NGS s John Stoll, Manager of Medicare Audit and Reimbursement, provided the following 2014 versus 2015 Hospice Self-Reporting Cap analysis for hospices in J6. Self Reported Hospice Cap: 2014 vs 2015 ITEM Difference Total # of J6 Hospices 1,118 1, % Timely Filing 84% 88% +4% Total Overpayment $46,304,246 $40,075,529 13% Mr. Stoll reported that NGS held four webinars regarding the hospice cap and self-reporting process in February and March and that the NGS hospice cap mailbox and NGSConnex were used by many hospices to file the self-reporting cap electronically. Mr. Stoll also stated that NGS will be conducting a three-year look back on the hospice cap, which should be completed by the end of August 2016 with any potential cap re-openings being identified at that time. Lastly, Mr. Stoll reminded participants that the finalization of the 2015 hospice cap year will occur in November and December of Upcoming 2016 Hospice Education NGS s Corrinne Ball reported that NGS will be offering the following hospice education programs that will be conducted via conference call and / or webinar: June 23 Let s Chat Hospice Billing July 13 Hospice Billing Basics Part 1 July 14 Hospice General Inpatient July 20 Hospice Billing Basics Part 2 July 20 Understanding the Effects of a Hospice Election and General Inpatient NGS requires providers to register for all education sessions through its website at Website users will need to enter their User ID and Password and make sure they are in the J6 Home Health & Hospice (HH&H) home page before clicking on the Training Events Calendar link under the Education and Training tab. NGS will be posting many more hospice and home health education sessions to the site, and HCA will notify the membership via our ASAP newsletter when the dates and times of these educational sessions are scheduled. 2

3 Medical Review and Appeals Data Findings Ms. Ball first provided a hospice medical review data update and noted that there was an increase in provider-specific probes and audits compared to the prior year which resulted in an annual percent change in reimbursement recovered of more than 30 percent, and that a particular focus of the medical review audits were in cases where a provider s Calendar Year 2015 average length of stay (ALOS) increased as compared to peers in the state. The following were the top hospice denial reason codes during the first quarter of 2016 (January 1 through March 31, 2016): Reason Code 55H1L: Terminal prognosis not supported (80% denial rate); Reason Code 55H1M: Documentation does not support a general inpatient level of care (7% denial rate); Reason Code 55H1B: Initial certification not signed timely by physicians (4% denial rate); and Reason Code 55H1F: Physician certification not sent with the documentation (4% denial rate) Ms. Ball then provided J6 Hospice Appeals Data for the first quarter of CY During the first quarter of CY 2016, NGS reviewed a total of 572 cases/claims at the redetermination appeal level which resulted in 75 cases being fully reversed (or 13%) and paid; 87% of the cases were affirmed, dismissed or partially reversed. Also during the first quarter of CY 2016, a total of 247 cases/claims were reviewed at the Qualified Independent Contractor (QIC) level which resulted in approximately 38% of the cases/claims being reversed and paid and 62% of the cases/claims being affirmed or dismissed. Finally, 16 cases reached the Administrative Law Judge (ALJ) level of appeal with 6 cases being fully reversed (38%) and 10 cases (62%) being affirmed. CERT Information and Data Findings CMS implemented the CERT program to measure improper payments in the Medicare fee-for-service (FFS) program. Under the CERT program, a random sample of all Medicare FFS claims are reviewed to determine if they were paid properly under Medicare coverage, coding, and billing rules. Once the CERT program identifies a claim as part of the sample, it sends a letter requesting the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim. The submitted documentation is then reviewed by medical review professionals to see if the claim was paid or denied appropriately. According to Ms. Ball, CMS s national CERT Error Rate Goal for the fiscal year (FY) 2015 reporting period is 12.1%. To accomplish this goal, NGS staff are reaching out to providers to provide information on appealing the claim or faxing additional or missing documentation directly to the CERT contractor with a cover letter (include the CERT ID #) to The following was the top reason that hospice claims were denied in J6 during the January 1, through April 31, 2016 time period in a CERT program audit: CERT Error Code 21: Insufficient Documentation Missing documentation for the initial certification; lacks required content for valid recertification such as face-to-face (F2F) visit and attestation; missing physician narratives for certain benefit periods; missing authenticated updated plans of care; missing valid written certification by the attending physician and hospice physician that contains the required narrative clinical findings prior to claim submission. 3

4 Ms. Ball concluded her update by informing participants that NGS is part of a CERT A/B MAC Outreach and Education Task Force with 7 other Medicare contractors who have a shared goal of reducing the national improper payment rate as measured by the CERT program. The joint collaboration of Medicare contractors has begun working to educate Medicare providers on widespread topics focusing on reducing their individual error rates across jurisdictions as well as communicating national issues of concern regarding improper payments to the Medicare program. NGS s CERT Task Force website can be found by going to the J6 HH&H home page, choosing the Medical Policy & Review, and then CERT. The CERT Task Force link is located towards the right of the new webpage. Updated Hospice Educational / Clinical Job Aids Ms. Ball asked Advisory Group participants for feedback on an upcoming hospice education webinar as well as one interactive learning tool which NGS will be offering and/or making available in the near future. The purpose of this review is to brief HCA and other provider representatives on important education programs or job aids that are being developed before they go live. This preview gives the provider community an opportunity to let members know about upcoming resources on the horizon and to share some of NGS s planned guidance in advance. Medicare Hospice General Inpatient Level of Care (webinar) In March of 2016, the federal Office of Inspector General (OIG) issued a report (OEI ) which found that nearly one-third (31%) of all hospices inappropriately billed Medicare for General Inpatient Care (GIP), resulting in approximately $268 million in overpayments. NGS developed this webinar to provide detailed information regarding the Medicare hospice benefit for GIP and to help deter hospices from inappropriately billing Medicare. During the webinar, NGS staff will educate participants about the following: Two levels of inpatient care under the hospice benefit; Definition of GIP; Acceptable locations for GIP (hospital, skilled nursing facility and hospice inpatient facility); Conditions that may require a GIP level of care; Conditions of Participation (CoPs) for inpatient services; and Acceptable scenarios. Medicare Hospice Reporting of Influenza, Pneumoccocal and Hepatitis B Vaccines NGS developed this course as an interactive learning tool. The purpose of the course is to help participants understand how a hospice should bill for influenza, pneumoccocal and hepatitis B vaccines on an institutional claim. During the course, participants will learn that Medicare covers influenza virus, pneumococcal and hepatitis B vaccines in accordance with coverage requirements, when furnished by a hospice to those beneficiaries who request them, including those who have elected the hospice benefit. Prior to October 1, 2016, hospices had to obtain a supplier number in order to bill Medicare for these services and submit the services on a professional claim. However, beginning on October 1, 2016, Medicare hospice providers may bill for vaccine services on institutional claims for effective date of service on or after October 1, 2016, per change request (CR) These services will be paid under the Medicare Physician Fee Schedule (MPFS). Since the vaccines are not specifically part of the Medicare hospice benefit, they must be billed on a separate claim that includes only the vaccines and their administration. These vaccines are submitted on an 4

5 Next Meeting institutional claim (Type of Bill 081X or 082X). The vaccines must also be billed with revenue code 0771 or No other revenue code may be on the claim for a vaccine. If other codes are on the claim, NGS will return the claim to the provider. The interactive course also includes a multiple choice self-test and a listing of many available resources that provide additional information for hospices billing for vaccines. NGS s next Hospice Advisory Meeting has been scheduled for October 19, 2016 in New York City and NGS will continue its policy of conducting three Hospice Advisory Meetings for state association representatives during CY HCA will provide a detailed Public Policy Memorandum to the membership after each of these meetings. HCA will also provide updates via our newsletter on any new NGS hospice-related issues or Medicare payment matters, including future CMS instructions to MACs, F2F guidance or audits; payments updated on the two-tier model or SIA adjustments; and upcoming hospice education programs. For further information, contact Patrick Conole at (518) or pconole@hcanys.org. 5