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Regulation – MythicalRegulation – Surveyor Suggestion Regulation – Someone Else's Accreditation Standards Professional Standards Agency PolicyAgency Tradition “We’ve always done it this way.”
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The Regulations
• Are the rules that carry out a statute• Address provision of care and payment• Define the minimum requirements a provider must meet to participate in the Medicare program
• Are designed to protect consumers
As advocates for hospice care, it is important to understand what the rules say, how they are applied and, if they don’t work, how to effect change
42 CFR 418 Subparts
A. General Provision and DefinitionsB. Eligibility, Election and Duration of BenefitsC. Conditions of Participation – Patient CareD. Conditions of Participation ‐ Organizational EnvironmentE. Conditions of Participation – Removed and Reserved F. Covered Services G. Payment for Hospice CareH. Coinsurance
The final rule creates an enduring record that may be used by many parties in the future
Comments count– CMS has to read every comment and respond in the final rule
– Volume of comments is noted
– Provides an opportunity to introduce new perspectives, suggest possibility of unintended consequences and to tactfully question assumptions
State Survey Agencies
• Survey and Certification S&C works with State Agencies SAs to monitor performance via the survey process
• Certain % of providers as specified by CMS are surveyed each year or following complaints
• If deficiencies are found, SA follows up to determine if they have been corrected or not
• By law, surveys must be unannounced
Deemed Status Surveys
Surveys may also be conducted by an Accrediting Organization (AO)
“However, there is an alternative to SA surveys for demonstrating compliance with the applicable CoPs. Accreditation based on a survey by a CMS‐approved Medicare accreditation program may be used by CMS to “deem” a provider or supplier as complying with the applicable regulatory standards.“ State Operations Manual (Chapter 1)
Surveys are conducted using 1. Subparts C & D of the hospice regulations – the
COPS – and the Interpretive Guidelines – the IGs2. State Licensure Rules3. The hospice’s own policies
The CoPs apply to all patients for whom the hospice provides care regardless of payor source
State Licensure Rules
Co‐exist with the CoPs; if both address a particular area, the higher standard prevails
Are state specific and vary from state to state (a few states do not have any)
Each state has own licensure survey frequency
If relocating to a new state, be aware that new licensure rules will apply
Reading the Conditions of Participation L Tag Condition of Participation Interpretive Guidelines
L520§418.54 Condition of participation: Initial and comprehensive assessment of the patient.
Interpretive Guidelines §418.54
L521 The hospice must conduct and document in writing a patient‐specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.
The comprehensive patient assessment must accurately reflect the patient’s current health status and include information to establish and monitor a plan of care. Hospices are not required to use specific forms or formats to document their initial or comprehensive assessments. They may choose to document patient specific comprehensive assessments in either written or electronic format provided the assessments are complete, readily identifiable and available in the patient’s clinical record.
Used to identify and organize deficiencies
The actual regulatory language
Guidance for surveyors and invaluable for providers. Read side‐by‐side with the CoPs
Additional Source of Sub‐Regulatory Information: The CMS On‐Line Only Manual
• Have been also been called Regional Home Health and Hospice Intermediaries RHHIs and Fiscal Intermediaries FIs
• Contract with CMS to process Medicare claims
• By law must be non‐governmental entities
• Performance assessed regularly by CMS and Office of the Inspector General OIG
• Contractor Error Rate Testing process CERT an addition means of performance assessment
• Review and make payment decisions based on Subparts B and the Conditions of Coverage and other information found in Subpart F
§418.200 Requirements for Coverage
To be covered, hospice services must meet the following requirements. 1. They must be reasonable and necessary for the palliation or
management of the terminal illness as well as related conditions. 2. The individual must elect hospice care in accordance with Sec. 418.24. 3. A plan of care must be established and periodically reviewed by the
attending physician, the medical director, and the interdisciplinary group of the hospice program as set forth in Sec. 418.56.
4. The plan of care must be established before hospice care is provided. 5. The services provided must be consistent with the plan of care. 6. A certification that the individual is terminally ill must be completed as
set forth in Sec. 418.22.
Subpart B: The Technical Coverage Provisions
Requirements that apply to Medicare patients only–Certification– Election / Revocation–Admission / Discharge– Transfers– Eligibility
1. Palmetto Government Benefits Administrators PGBA
2. Cahaba Government Services CGS
3. National Government Services NGS
The Medicare QIOs• Formerly known as Peer Review Organizations, the PRO, now
known as Quality Improvement Organizations QIOs
• Non‐profits; up until 2014 re‐organizations one in each state
• Hospices interact with them when issuing a notice of Medicare Non‐Coverage NOMNC as part of the Expedited Determination Process
• Part of Beneficiary Notice Initiative BNI; information is found in Chapter 11 of the Claims Processing Manual regulations and at link below rather than with the rest of the hospice regulations
Beneficiary and Family Centered Care Quality Improvement Organizations carry out the case review function and will handle all first level beneficiary appeals resulting from hospice discharges for ineligibility.
QIN‐QIOs
Quality Innovation Network ‐Quality Improvement Organization will be responsible for working directly with providers and communities on quality initiatives. Hospices can expect to have more interactions with these in upcoming years.
A Note on Medicaid
• Medicaid hospice benefit is almost identical to HMB
• No separate provider certification process
• States have separate reporting rules
• No routine survey visits
• States may process claims themselves or work with fiscal agents
Medicare Internet Only Manuals • CMS program issuances, day‐to‐day operating instructions, policies, and
procedures
• Based on statutes, regulations, guidelines, models, and directives
• Used by providers, contractors, Medicare Advantage organizations and state survey agencies to administer CMS programs
• Organized by function rather than by provider
• Of most interest to hospices – Benefit Policy Manual – Chapter 9– State Operations Manual (Surveyor Interpretive Guidelines – Appendix M)– Claims Processing Manual – Chapter 11– Benefit Integrity Manual
www.cms.hhs.gov/Manuals/IOM/list.asp
CMS Program Transmittals
• Vehicle used to communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS program manual
• Cover page (or transmittal page) summarizes the change
• Each has both a transmittal and a change request number; the latter is what they are commonly referred to as
• Material ultimately added to the manual identified on transmittal page
• Medicare Learning Network will also issue an MLN Matters article on new information; usually a bit easier to understand but not always exactly correct
[email protected] information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations.
Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
The Four Faces of Medicare
A. General Provision and DefinitionsB. Eligibility, Election and Duration of BenefitsC. Conditions of Participation – Patient CareD. Conditions of Participation - Organizational EnvironmentE. Conditions of Participation – Removed and ReservedF. Covered ServicesG. Payment for Hospice CareH. Coinsurance
visit www.hospicefundamentals.com or call us at 919-491-0699
Code of Federal RegulationsTitle 42, Volume 2, Parts 400 to 429
PART 418 — HOSPICE CARE
42 CFR 418 Subparts
Centers for Medicare & Medicaid Services
Medicare Administrative Contractors
Assure that providers are paid for services
SUBPARTS B, F & G
State Survey &Certification Agencies
Monitor providers to assure that they are meeting the standards
SUBPARTS C & D
Quality ImprovementOrganization
Provide a process for beneficiaries to appeal provider decisions