Regulations: A Year in Review and A Look to the Future.

Regulations:

A Year in Review and

A Look to the Future

Outline• Nebraska Hospice

Landscape• State Licensure and

Regulations• Survey Deficiencies• Hospice Wage Index• Quality Reporting• Proposed Rulemaking• Change Requests

• Provider Bulletins• Hospice Scrutiny

– OIG– MEDPAC– RAC– PEPPER

• Fiscal Intermediary Information

• Resources

Nebraska Hospice Admissions 2002-2012

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

41604472

47355192

55115811

6529 6603

7172

77478277

Nebraska Hospice Admissions 2002-2012

  Nebraska National

Population 1,855,525 313,878,238

Total Deaths 15,022 2,512,991

Medicare Beneficiaries Deaths 12,721 2,022,574

Medicare Hospice Beneficiary Admissions 7,84762% of Medicare deaths

1,257,73562% of Medicare deaths

Medicare Hospice Beneficiary Deaths 5,95346.8% of Medicare deaths

897,37944.4% of Medicare deaths

Medicare Hospice Total Days of Care 468,804 days 89,817,308 days

Medicare Hospice Mean Days/BeneficiaryMedicare Hospice Median Days/Beneficiary

60 days21 days

71 days25 days

Medicare Hospice Discharged Alive 12% 18%

Medicare Hospice Total PaymentsMedicare Hospice Mean Payment/Beneficiary

$71,282,532$9,084

$14,882,743,292$11,842

2012 Demographics & Hospice Utilization

2012 Medicare Hospice Beneficiaries Location of Care (days)

Compare: Nebraska

Compare: National

0% 20% 40% 60%

28%

57%

57%

24%

14%

17%

1%

1%

1%

1%All Other Settings

Inpatient Hospice

Assisted Living Facility

Skilled/Non-Skilled Nursing Facility

Home

2012 Medicare Hospice BeneficiariesLevels of Care (days)

Compare: Nebraska

Compare: National

96.0%

97.0%

98.0%

99.0%

100.0%

98.9%

97.5%

0.8%

1.9%

0.1%

0.3%

0.1%

0.4%

Cont. Home CareRespite CareGeneral InptRoutine Home Care

2012 Length of Stay

Nebraska

0% 20% 40%

9%

12%

21%

26%

29%

7 days or less

8-29 days

30-89 days

90-179 days

180+ days

State of Nebraska

Nebraska Department of Health and Human Services

Medicaid Physical Health Managed Care

• RFP to be released this summer and will be effective July 1, 2015 – will add hospice and certain other services

• Medicaid hospice services for persons in nursing facilities or receiving Aged and Disabled Waiver assisted living services will continue to be excluded

Nebraska Department of Health and Human Services

Managed Long Term Services and Support (MLTSS)

• Medicaid MLTSS RFP will not be released prior to September 1, 2015 and will not go live prior to January 1, 2017

Nebraska Department of Health and Human Services

• Pamela Kerns, RN, [email protected]

• Hospice-specific Web page

http://dhhs.ne.gov/publichealth/Pages/crl_hcddlabs_hospice_hospice.aspx

Nebraska Hospice Licensure

Title 175, Chapter 16

Effective May 1, 2010

http://www.sos.state.ne.us/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-175/Chapter-16.pdf

State Operational Manual (SOM)Updated – March 7, 2014All Chapters:

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984.html

Appendix M – Hospice

http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

CMS CY2013 Survey Deficiency Data

• 3,970 Active hospice providers• 1,301 recertification surveys• 33% of active providers surveyed

CMS CY2013 Survey Deficiency Data

• L0543 – Plan of Care– POC not individualized; missing or incomplete

documentation; lack of IDT collaboration; lack of evidence of patient/family collaboration of POC goals

• L0545 – Content of Plan of Care– Missing or inaccurate documentation; physician

orders missing

CMS CY2013 Survey Deficiency Data

• L0530 – Content of Comprehensive Assessment– Incomplete medication profiles; lack of updated

medication profiles in patient’s home

• L0555 – Coordination of Services– Services provided by IDT that were not on POC

and interventions on POC that were not provided

CMS CY2013 Survey Deficiency Data• L0547 Content of Plan of Care

– POC contained services missing frequency of care to be provided

• L0591 – Nursing Services– Hospice aides performing tasks outside of

scope of practice; RN on-call issues; delays in RN visits; RN unable to visit frequency for pt needs

CMS CY2013 Survey Deficiency Data

• L0629 – Supervision of Hospice Aides– Supervision of hospice aides varied from 16

days to more than 30 days

• L0557 – Coordination of Services– RN documented at assessment patient declined

chaplain as involved with community church – chaplain documented repeated messages to schedule a visit; Patient had private duty aide services – no documentation to show coordination of care with private agency

CMS CY2013 Survey Deficiency Data

• L0533 – Update of Comprehensive Assessment– RN performed dyspnea assessment but did not

communicate change in status to IDT – other members of IDT did not take into consideration when updating the POC

• L0671 – Clinical Records– Lacked patient signature forms, IDT notes

including aide, volunteer, and chaplain

Patient Protection and Affordable Care Act

(PPACA)

Hospice Payment Reform

• Will occur no earlier than Oct. 1, 2013, or FY2014

• Revise methodology for RHC• Not required to change payment for other

levels of care

Hospice Payment ReformMedicare Hospice Payment Reform: Hospice Study Technical Report, April 24, 2013

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Hospice-Study-Technical-Report-4-29-13.pdf

Medicare Hospice Payment Reform: Analyses to Support Payment Reform, Abt Associates, May 1, 2014

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/May-2014-AnalysesToSupportPaymentReform.pdf

Medicare Care Choices Model

• Initiative to test new payment and service delivery model

• Beneficiary to receive palliative care services from certain hospices while concurrently receiving curative services

http://innovation.cms.gov/initiatives/Medicare-Care-Choices/

http://innovation.cms.gov/initiatives/Medicare-Care-Choices/faq.html

Hospice Wage Index

FY2014 Medicare Wage IndexCBSA Code

State County Code

County Name FY2014 Wage Index

FY2014Routine Home Care

FY2014Continuous Home Care

FY2014 Inpt

Respite

FY2014General

Inpt

NE 28 2000 84 Other Counties

0.88940.8937

144.20147.55

841.57861.15

151.76155.18

645.04659.89

NE 30700 28540 Lancaster and Seward

0.99060.9553

155.05154.29

904.90900.47

160.60160.67

690.01687.81

NE 36540 28270 Cass, Douglas, Sarpy, Saunders, and Washington

1.02220.9847

158.44157.51

924.67919.23

163.36163.29

704.05701.14

NE 43580 28210 Dakota and Dixon

0.91760.9248

147.22150.96

859.21881.00

154.22157.95

657.58673.99

*Red amount indicates proposed FY2015 rates as published in Proposed Rule May 2, 2014

Budget Control Act of 2011 “Sequestration”

Sequestration Order issued March 1, 2013

• Medicare Fee-for-Service claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.

https://www.cgsmedicare.com/parta/pubs/news/2013/0313/1005.html

CMS FY2015

Hospice Wage Index Proposed Rule

May 2, 2014http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Regulations-and-Notices-Items/CMS-1609-P.html

Key Elements in FY2015 Proposed Rule• Data analysis for consideration in hospice payment reform• No hospice payment reform proposed for FY2015• Changes Proposed

– Time frames for Notice of Election (NOE) and new Notice of Termination/Revocation

– Attending physician is patient decision– Cap self report and overpayment expected 5 months after close of cap

year– Hospice quality reporting updates– ICD-9 to ICD-10 Update

• Payment Update– 2% payment update (net 1.3%) for FY2015– Sequestration means NO payment update for FY2015

• Comments Requested– Definitions of “terminal illness” and “related conditions”– Part D and hospice communication

Analyses for Payment Reform1. No skilled visits in last 48 hours of life

2. Analysis of GIP, Continuous Home Care and Inpatient Respite

3. Live dischargesa. Frequency of live discharges

b. Live discharges and readmissions after hospital stay

4. Medicare expenditures in Part A and B outside the MHB

5. Medicare expenditures in Part D when patient has elected hospice

% of Patients with No Skilled Visits

Days before Death % of Patients

Last day of life 28.9% of patients

Last 2 days of life

14.4% of patients

Last 3 days of life

9.1% of patients

Last 4 days of life

6.2% of patients

Skilled visits include nurse, social worker, therapies

Lowest % of Patients with No Visits in Last 2 Days of Life

State % with No Visits

WI 5.7%

ND 7.3%

VT 7.5%

TN 7.5%

KS 8.5%

Highest % of Patients with No Visits in Last 2 Days of Life

State % with No Visits

NJ 23%

MA 22.9%

OR 21.2%

WA 21%

MN 19.4%

Percentage of days by level of care

Level of Care Percentage of Total Days

Routine Home Care 97.4%

Continuous Home Care 0.4%

Inpatient Respite Care 0.3%

General Inpatient Care 1.9%

GIP Utilization

• Patient utilization:

77.3% of patients electing hospice did not have a GIP stay during their hospice election

• Hospices providing GIP

21.1% of hospices did not bill for a single day of GIP in CY2012

GIP Utilization• National average =

1.9% of days are GIP

• Provide GIP– 5-10% = 195

hospices – 10% or more = 46

hospices

Any GIP Provided?

Number of

Hospices

No 969

Yes 2,758

Location of GIP

% of Total0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

68.0%

24.9%

5.5%

1.6%

Hospice Inpt FacilityHospitalSkilled Nursing FacilityMulti

Length of GIP Stay by Location

Average Length of Stay in Days0

1

2

3

4

5

6

7

5.5

6.1

4.5 4.7

AllInpatient HospiceInpatient HospitalSNF

Continuous Home Care DataHospice Characteristic Billing Continuous

Home Care

Hospices that billed Continuous Home Care

42% of hospices billed at least one day of CHC

4 hospices billed more than 10% of their days as CHC

40 hospices accounted for 46% of all CHC days

1 hospice > 25% of all CHC days

9.4% of hospices > 50% provided to patients in nursing homes

Inpatient Respite Utilization

• Patient Utilization

3.4% in CY2012 used at least 1 day

• Hospices providing Inpatient Respite

26% of hospices did not bill for a single day of IRC during CY2012

Ongoing Monitoring and Review

• CMS states ongoing monitoring of GIP, CHC, and IRC utilization

• Review will include:– Identify hospices with aberrant utilization patterns– Identify hospices that may be in violation of the CoPs or

payment regulations• Hospices identified will be referred to

• Survey and Certification• Office of Financial Management• Center for Program Integrity

for further investigation

Live DischargesYear % of Live Discharges

2000 13.2%

2012 18.1%

July 1 2012 Revocations separated from hospice-initiated live discharges

2013 data

Revocations 39%

No longer terminally ill 58%

Rates of Live Discharges

2010 Live Discharge rates by state• CT 12.8%• MS 40.5%

% of Patients Discharged

Alive

Number of Hospices

0 – 9.9% 1,601

10% - 19.9% 1,315

20% - 29.9% 371

30% - 39.9% 133

40% + 282

Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012

100% Live Discharge Rate• 71 hospices in CY2012

– Average length of stay: 193 days – National average lifetime LOS: 95.4 days

• CMS states: We have shared this information with the Office of Financial Management and with the Center for Program Integrity for their review and follow-up.

Live Discharge and Readmissions

Hospice Discharge

Hospital Admission

Expensive test/procedure$126 M

Hospital Discharge

Hospice Readmission

2010 Data

13,770 patients of 182,172 live discharges – 7.5%

Live Discharge and Readmission by State

MS VA

OK TX

AL NJ

SC GA

MD LA

Medicare A and B Outside Hospice BenefitPart A or B Service Percentage of $$ Spent

DME 7.1%

Inpatient care 28.6%

Outpatient Part B services 16.9%

Other Part B services (physician, practitioner, labs and diagnostic tests, ambulance transports, and physician office visits)

37.4%

Skilled Nursing Facility Care 5.7%

Home Health Care 4.5%

States where Medicare A and B Outside the Hospice Benefit is Highest

WV

FL

TX

MS

SC

Part D Expenditures During a Hospice Stay

• CY2012– Total Part D spending: $417.9 million– Paid by Medicare: $334.9 million

• All drug types• Paid by:

– Medicare– States– Beneficiaries– Other payers

Highest Part D Expenditures by State

ID

WV

AL

OK

CY2012 Total Non-Hospice Medicare Spending

For beneficiaries after hospice election

• Parts A & B: $710.1 million • Part D: $334.9• TOTAL: $1.3 Billion dollars

Note: 51.6 % of $1.3 billion -- 373 hospices• Average total per beneficiary: $1,289 in non-

hospice costs

PROVISIONS OF PROPOSED RULE

Notice of Election

• File the Notice of Election with MAC within 3 calendar days after effective date of election

• Failure to submit:Medicare will not cover and pay for days of hospice care from the effective date of election to the date of filing of the NOE. Provider may not bill beneficiary.

NOE Filing• File Notice of Election (NOE) as soon as

possible after the election occurs• If filed ASAP:

– Limits ability of other Part A, B and D providers to bill in error

– Provides up to date information on face-to-face encounter

– Identify current benefit period– Provide smooth transitions for sequential billing

Attending Physician

• The attending physician has been identified by the patient and was his or her choice

• NEW: File a change of attending physician form with the hospice that states that the patient is changing his or her attending physician

Notice of Termination • Filing a Notice of Termination of Election

– When hospice election is ended due to discharge, the hospice must file a notice of termination/revocation of election within 3 calendar days after the effective date of the discharge, unless it has already filed a final claim for that beneficiary.

Notice of Revocation

• Filing a Notice of Revocation of Election. – When the hospice election is ended due to

revocation, the hospice must file a notice of termination/revocation of election with its Medicare within 3 calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary

Payment Penalty for No Quality Reporting

• For FY 2014 and subsequent fiscal years– if the hospice does not submit hospice quality data,

payment rates are equal to the rates for the previous fiscal year increased by the applicable market basket percentage increase, minus 2 percentage points.

– Applies only to the fiscal year involved – Will not be taken into account in computing the

payment amounts for a subsequent fiscal year.

New Cap Reporting

• File its cap determination notice with its Medicare contractor

• No later than 5 months after the end of the cap year (that is, by March 31st)

• Remit any overpayment due at that time. • If a provider fails to file, payments to the hospice

would be suspended in whole or in part, until a self-determined cap determination is filed

Data Submission for Quality Reporting

• Data Submission Requirements under the Hospice Quality Reporting Program. – Hospices must submit to CMS data on

measures selected in a form and manner, and at a time, specified by the Secretary.

Submission of HIS data

• Submission of Hospice Quality Reporting Program data. – Complete and submit an admission Hospice

Item Set (HIS) and a discharge HIS for each patient admission to hospice, regardless of payer or patient age.

– HIS is a standardized set of items intended to capture patient-level data.

Contract with CAHPS® Vendor

• Medicare-certified hospices must contract with CMS-approved vendors to collect the CAHPS® Hospice Survey data on their behalf and submit the data to the Hospice CAHPS® Data Center.

CAHPS Survey Data CollectionDeaths in Prior Calendar Year Survey and Reporting

< 50 deaths Exempt from CAHPS data collection and reporting

50 to 699 deaths

n = 2,326 hospices

Survey and report all cases

>= 700 deaths

n = 274 hospices

Sample of 700 will be drawn under equal probability design

Quality Reporting Appeals

• Reconsiderations and appeals of Hospice Quality Reporting Program decisions. – May request reconsideration of a CMS decision

about Hospice Quality Reporting Program for a particular reporting period.

– Reconsideration requests to CMS no later than 30 days from the date identified on the annual payment update notification provided to the hospice.

Quality Reporting Appeals

• Reconsiderations and appeals of Hospice Quality Reporting Program decisions. – Submission requirements available on the CMS

Hospice Quality Reporting Web site on CMS.gov.

– A hospice dissatisfied with CMS decision may file an appeal with the Provider Reimbursement Review Board

CMS REMINDER: GUIDANCE ON DETERMINING BENEFICIARIES’ ELIGIBILITY FOR HOSPICE

Eligibility

• Reminder that the hospice medical director must consider at least the following information per our regulations at §418.25 (b):– Diagnosis of the terminal condition of the patient– Other health conditions, whether related or

unrelated to the terminal condition.– Current clinically relevant information supporting

all diagnoses.

Resources for Eligibility

• Multiple public sources available to assist in determining whether a patient meets Medicare hospice eligibility criteria: – industry specific clinical and functional assessment tools – information on MAC websites

• We expect hospice providers to use the full range of tools available to make responsible and thoughtful determinations regarding terminally ill eligibility

HOSPICE EHR PARTICIPATION

Feedback on Hospice EHR

• Have hospices have adopted an EHR?• What functional aspects of the EHR do hospices find most

important? – ability to send or receive transfer of care Information– ability to support medication orders/medication reconciliation

• Can hospice EHR communicate with other healthcare providers?– acute care hospitals– physician practices– skilled nursing facilities? Ins decision

• Should CMS develop electronic clinical quality measures for hospice providers? Benefits and limitations?

ICD-9 TO ICD-10 CODING AND TIMELINE

ICD-9• ICD-9-CM diagnosis codes will continue to

be used for hospice claims reporting until October 1, 2015

• Diagnosis reporting on hospice claims must adhere to ICD-9-CM coding conventions and guidelines

• Applies to both the principal diagnosis and the reporting of additional diagnoses

Medicare Code Editor Edits

• Will implement certain edits from Medicare Code Editor (MCE)

• Report errors in the coding of claims data• ALL hospice claims effective October 1, 2014 or

later• Inappropriate principal or secondary diagnosis

codes, per ICD-9-CM coding conventions and guidelines?

• Returned to Provider (RTP) for correction and resubmission prior to payment

Multiple Diagnoses on Claim

Year% of claims

submitted with one diagnosis

FY2010 77.2%

First quarter (10/1/2012 through 12/31/2012)

72%

FY2013 67%

COMMENTS REQUESTED BY CMS FOR FUTURE RULEMAKING

CMS REQUESTED COMMENTS ON DEFINITIONS OF “TERMINAL ILLNESS” AND “RELATED CONDITIONS”

Definition of Terminally Ill

• CMS states:

“Because hospice care is unique in its comprehensive, holistic, and palliative philosophy and practice, we want to ensure that the hospice services under the Medicare hospice benefit are preserved and not diluted, or unbundled in any way.”

Possible Definition of Terminal Illness

• “Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure;

• not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of six months or less”.

Possible Definition of Related Conditions

• “Those conditions that result directly from terminal illness; and/or – result from the treatment or medication management of

terminal illness; and/or – which interact or potentially interact with terminal illness;

and/or – which are contributory to the symptom burden of the

terminally ill individual; and/or – are conditions which are contributory to the prognosis that

the individual has a life expectancy of 6 months or less”.

CMS REQUESTED COMMENTS ON COORDINATION OF BENEFITS PROCESS AND APPEALS PART D PAYMENT FOR DRUGS WHILE BENEFICIARIES ARE UNDER A HOSPICE ELECTION

Comments Requested on Possible Changes to Part D Regulations

• Would require that a Part D sponsor communicate and coordinate with Medicare hospices in determining coverage for drugs whenever– a coverage determination process is initiated or – a hospice furnishes information regarding a

beneficiary’s hospice election and/or drug profile

Comment on Hospice Initiated Communication

• Report a beneficiary’s hospice status• Includes

– notice of election (NOE)– Notice of termination/revocation (NOTR)

• May also provide– drug profile information– identification of drugs unrelated to the terminal

illness or related conditions – explanation of why the drug is unrelated

Comment on Hospice Initiated Communication

• Permits hospices to initiate communication with the beneficiary’s Part D sponsor

• Considering requiring Part D sponsors to accept NOE and NOTR information as use for coverage until official CMS notification is received

• Expect sponsors to have processes in place to confirm CMS-reported data and communicate with hospice

Comment on Part D Sponsors using Proposed Definitions

• Propose that Part D sponsor be required to use the criteria described in the definitions of “terminal illness” and “related conditions”

• Determine whether drug is unrelated to the terminal illness and related conditions

• Satisfies the beneficiary-level hospice PA

Comment on Independent Review Process

• CMS considering• Separate and distinct from the enrollee

appeals process • Independent Review Entity (IRE) decision

would be binding on both the Part D sponsor and the hospice

HOSPICE COORDINATION OF PAYMENT WITH PART D SPONSORS AND OTHER PAYERS

Reports from Beneficiaries

• Anecdotal reports from Medicare hospice beneficiaries

• They are not receiving medications related to their terminal illness and related conditions from their hospice

• One reason stated – “those medications are not on the hospice’s formulary”

Hospice Formulary

CMS states:• If the drugs on the hospice formulary are

not providing the relief needed, then the hospice must provide alternatives in order to relieve pain and symptoms

• EVEN if it means providing drugs that are not on the hospice formulary

CoP for Drug Coverage

• 418.202(f), – Hospices are to cover all drugs which are

reasonable and necessary to meet the needs of the patient in order to provide palliation and symptom management of the individual's terminal illness and related conditions.

• Treatment decisions should be driven by clinical appropriateness, rather than costs

CMS Comment on Medication Management

CMS states:– Hospices should use thoughtful clinical

judgment, with a patient-centered focus, when developing the hospice plan of care, including the recommendations for medication management

PART D AND HOSPICE

HTTP://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FOR-SERVICE-PAYMENT/HOSPICE/DOWNLOADS/2015-PART-D-HOSPICE-GUIDANCE.PDF

What we know• Ongoing meetings on Part D and hospice

with no easy resolution• Part D plans instructed to continue current

practices through 2015• Some hospices continue to request Part D

payment for vitamins, calcium, nasal spray and throat lozenges

• Some Part D plans refuse to pay for any drugs for hospice patients

Relatedness

• No clear line between related and unrelated to terminal illness and related conditions

• Could be contributing to prognosis…• Determination needs:

– Expertise of hospice physician– Documentation in medical record of “why” the

drug is unrelated

Four Buckets of “Relatedness”

RELATED and

HELPFUL UNRELATEDand

HELPFUL—PART DCOVERS

UNRELATED, BUT NO LONGER HELPFUL

RELATED, BUT NO LONGER HELPFUL or

NOT ON FORMULARY

26

Standardized Form• Developed by the National Council of

Prescription Drug Programs (NCPDP)• CMS has stated that they have reviewed the

form and “tweaked” it in a couple of places• Will begin sending it through the

Paperwork Reduction Act (PRA) process for approval

• May take years…

Quality Reporting

ACA (HEALTH REFORM LEGISLATION)

• Requires hospices to submit data on selected quality measures to receive annual payment update for fiscal year 2014 and subsequent fiscal years.

• Beginning in FY 2014, hospices that do not submit required quality measure data will have their market basket rate reduced by 2% for that FY.

ACA (HEALTH REFORM LEGISLATION)

• CMS must take steps to make hospice quality measure data available to the public (no timeline given).

• The published quality measures must receive endorsement from a consensus body (e.g. NQF), with exceptions.

FIRST TWO YEARS

Measures

1. NQF #0209:Comfortable Dying = Percentage of patients

who were uncomfortable because of pain on the initial assessment (after admission to hospice) whose pain was brought to a comfortable level within 48hours

FIRST TWO YEARS

2. Structural Measure:

Participation in a QAPI program that includes at least 3 quality indicators related to patient care

2014 FINAL RULE

Data collection and submission for QAPI Structural measure and NQF 0209 are discontinued

CY 2013 was the last data collection; CY 2014 was the last data submission for these measures

FY 2015 is the last payment determination year for these measures

2014 QUALITY REPORTING

NQF #0209 and QAPI Structural Measures –

No longer required for quality reporting

*Comfortable Dying measure still supported by NHPCO

QUALITY REPORTING - HIS

Hospice Item Set (HIS)

• Patient level data collection tool

• Data used to calculate 7 new measures

QUALITY REPORTING - HIS

Six NQF Endorsed Measures:

NQF 1634 Hospice and Palliative Care -- Pain Screening

NQF 1637 Hospice and Palliative Care –Pain Assessment

NQF 1638 Hospice and Palliative Care -- Dyspnea Treatment

NQF 1639 Hospice and Palliative Care -- Dyspnea Screening

QUALITY REPORTING - HIS

Six NQF Endorsed Measures:

NQF 1617 Patients Treated with an Opioid who are Given a Bowel Regimen

NQF 1641 Treatment Preferences

One Modified NQF Measure:

NQF 1647 Beliefs/Values Addressed

QUALITY REPORTING - HIS

For specifications of proposed measures --

National Quality Forum (NQF)

Final Report on Palliative and End of Life Measures

http://www.qualityforum.org/Projects/Palliative_Care_and_End-of-Life_Care.aspx#t=1&s=&p

=

(or Google search: NQF Palliative end of life measures endorsement summary)

QUALITY REPORTING - HIS

• Implementation starts July 1, 2014

• Hospices who fail to report quality data via the HIS system in 2014 will have a 2% market basket reduction for FY2016

• Reconsideration request process

QUALITY REPORTING - HIS

All Medicare-certified hospices must submit.

• New but on track for initial survey – need to prepare

• Newly certified hospices that receive notice of their CMS certification number on or after November 1, 2014 excluded (proposed)

QUALITY REPORTING - HIS

Must collect and submit data on admission and discharge of every patient

• All payers

• All ages

QUALITY REPORTING - HIS

Quality measure scores not calculated for all patients -

18 years and older LOS of > 7 days for some

But still need to collect/submit for all admissions starting 7/1/2014

QUALITY REPORTING - HIS

Two Forms

ADMISSION • Sections A, F, I, J, N, Z• Contains administrative items and care process items.

DISCHARGE• Sections A, Z• Contains a limited set of administrative items and 2

discharge items.

QUALITY REPORTING - HIS

The HIS is not –

a patient assessment instrument and will not be administered to the patient and/or family or caregivers

The HIS is -

a standardized mechanism for abstracting data from the medical record

QUALITY REPORTING- HISRecord Completion and Data Submission

• Electronically online• Ongoing basis• 14 days from admission to complete HIS-Admission

record • 7 days from discharge to complete HIS-Discharge record• 30 days from a patient admission or discharge to submit

QUALITY REPORTING- HIS

Have policy/procedure in place related to:

Creation of HIS

Retention of HIS submission

QUALITY REPORTING - HIS

CMS Resources – Data Collection

CMS HQRP Web site – Hospice Item Set page– HIS Manual and Change Table– HIS Training slides – Fact Sheet– Q & A

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html

Quality Help Desk: [email protected].

QUALITY REPORTING - HIS

CMS Resources – Data Submission

CMS HQRP Web site - HIS Technical Information page

QTSO Website– Technical Training modules (Webex)– HART Training modules– Registration for IDs

https://www.qtso.com/hospice.html

https://www.qtso.com/hart.html

Technical Support QTSO Help Desk: [email protected]

HOSPICE CAHPS(EXPERIENCE OF CARE SURVEY)

• Post-death caregiver survey• Consumer Assessment of Healthcare Providers and

Systems (CAHPS) family of surveys• Borrows heavily from NHPCO FEHC• Requires contract with a vendor for survey

administration

HOSPICE CAHPS

Implementation

Mandatory “dry run” for at least 1 month in first quarter of CY 2015•Continuous participation starts April 1, 2015 • Participation will affect the FY 2017 payment determination

year•Dedicated survey website (TBA)•Reconsideration request process•Will be included in public reporting eventually

HOSPICE CAHPS

Eligibility:• Patients over age of 18• LOS of at least 48 hours• No non-familial legal guardians• No non-USA home addresses• No known caregiver or contact information• Request not to be contacted

HOSPICE CAHPS

• Must use a vendor approved by CMS• List of approved vendors provided close to

the launch of national implementation. • Summer 2014 interested vendors may apply

to become an approved vendor

HOSPICE CAHPS

Measures derived from survey questions:

1. Hospice Team Communication (5)

2. Getting Timely Care (2)

3. Treating Family Member with Respect (2)

4. Providing Emotional Support (2)

Source = proposed rule

HOSPICE CAHPS

5. Getting Help for Symptoms (4)

6. Information Continuity (1)

7. Understanding the Side Effects of Pain Medication (1)

8. Getting Hospice Care Training (Home Setting of Care Only) (4)

Source = proposed rule

HOSPICE CAHPSSampling:

• Hospices send caregiver information to vendors each month

• Hospices with fewer than 50 decedents during the prior calendar year are data collection and reporting requirements for payment determination.

• Hospices with 50 to 699 decedents in the prior year (n = 2,326 in 2012) will be required to survey all cases.

• For large hospices with 700 or more decedents in the prior year (n =274 in 2012), a sample of 700 will be drawn under an equal-probability design.

Change Requests (CRs)

July 2013 through

June 2014

Medicare Benefit Policy Manual

Chapter 9 - Coverage of Hospice Services Under Hospital Insurance

(Rev. 156, 06-01-12)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf

CR 8727 Updates and Clarifications to the Hospice Policy Chapter of the Benefit

Policy Manual

Released May 1, 2014

Effective Date: August 4, 2014• Updates the hospice policy chapter to incorporate

policy language from existing regulations, prior rules, an OIG report and two CR, and to clarify existing policy. No changes were made to existing policy.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R188BP.html

CR 8620 CWF Editing for Vaccines Furnished at Hospice - Correction

Released February 6, 2014• Was rescinded and replaced by Transmittal

1737, dated April 28, 2014

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1339OTN.pdf

CR 8569 Enforcement of the 5 day Payment Limit for Respite Care Under

the Hospice Medicare Benefit

Released February 5, 2014• Was rescinded and replaced by Transmittal

2928 to restore information from CR8358 that was erroneously omitted.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2867CP.pdf

CR 8358 Additional Data Reporting Requirements for Hospice Claims

Released January 31, 2014• To provide clarifying information and

examples; technical corrections of Transmittal 2747, dated July 26, 2013

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2864CP.pdf

CR 8358 Additional Data Reporting Requirements for Hospice Claims

Released July 26, 2013

Effective Date: April 1, 2014

Implementation Date: January 6, 2014• Additional date for: visit reporting for GIP,

reporting facility NPI; reporting of infusion pumps and prescription drugs

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/R2747CP.pdf

Provider Bulletins (PBs)

July 2013 through

June 2014

Provider Bulletin 13-65

FFY 2014 Medicaid Hospice Rates• Issued: September 9, 2013• Effective Date: October 1, 2013

http://dhhs.ne.gov/medicaid/Documents/pb1365.pdf

Provider Bulletin 13-79

January 1 through December 31, 2014 Base Rates for Levels 101 through 105• Issued: December 11, 2013• Effective Date: January1, 2014

http://dhhs.ne.gov/medicaid/Documents/pb1379.pdf

Provider Bulletin 14-21

Provider Enrollment Process Changes• Issued: April 2, 2014• Effective Date: May 1, 2014

http://dhhs.ne.gov/medicaid/Documents/PB%2014-21.pdf

Provider Bulletin 14-22

Nebraska Medicaid Recovery Audit Contract (RAC) Program• Issued: April 29, 2014

http://dhhs.ne.gov/medicaid/Documents/pb1422.pdf

Revalidation of Provider Enrollment

All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from their MAC.

Revalidation of Provider Enrollment

• Letters to be sent between now and 6/23/2015

• Will be mailed (USPS) to address on file

CMS website

http://www.cms.gov/MedicareProviderSupEnroll/

Hospice

Scrutiny

Office of Inspector General (OIG)

Fiscal year 2014 work plan related to hospice: • Hospice in assisted living facilities

– ALF residents have the longest lengths of stay in hospice care

• Hospice General Inpatient Care– Review the appropriate use of hospice general inpatient care

http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf

MedPacMarch 2014 Report

Recommendation to “carve-in” the Medicare Hospice Benefit for Medicare Advantage participants

HealthDataInsights, Inc. RAC for Region D

• Listed audit issue for hospice– Face-to-Face Evaluation for Re-certification of

Hospice Care• Medical documentation will be reviewed to

determine timeliness of the face-to-face re-certification

https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

PEPPERProgram for Evaluating Payment

Patterns Electronic Report

Hospice Target Areas

Live Discharges

Long Length of Stay

PEPPERA report summarizing a hospice’s Medicare claims data in areas of risk.• Compares a hospice’s claims data with

aggregate statistics for other hospices in the state, MAC/FI jurisdiction and the nation

• Data obtained from the UB-04

PEPPERPEPPER does not identify the presence of improper payments, but can be used as a guide for auditing and monitoring efforts

Training and Resources:

http://pepperresources.org/TrainingResources/Hospice.aspx

Fiscal Intermediary

Information

CGS

1-877-299-4500

Option 1: Hospice Customer Service RepOption 2: EDI Customer Service Rep

Option 3: Provider Enrollment department

Option 4: Overpayment Recovery department

Interactive Voice Response (IVR) number

1-877-220-6289 for beneficiary eligibility, claim status, check and general information

myCGS Web Portal

• New enhancements• If your organization/office is not already

signed up for the myCGS web portal, go to http://www.cgsmedicare.com/mycgs/index.html

CGSClaims Denied

February 2014 – May 2014

277,779 hospice claims submitted

43,488 claim submission errors

3,406 hospice claims reviewed

2,164 denied

CGS Hospice Medical ReviewTop Denials for February – May 2014

5PTER: Six-month prognosis not supported

5PPOC: Plan of care not updated timely

5PCER: Certification requirements not met

56900: ADR information not received

5PNOE: Election Statement incomplete, missing, untimely

Medical Review Hierarchy

Level of care

Physician visits

Terminal status

Plan of Care (POC)

including review of the POC every 15 days

Certifications including face-

to-face (FTF)

Election Statement

CGS Current Widespread Edits• Length of stay > 730 days• Seven or greater GIP days on claim• Code Q5003 and Q5004 with primary diagnosis of

Debility, unspecified (799.3) and length of stay > 180 days

• Length of stay between 150-365 days and non-oncologic diagnosis code

• Previous denials for selected beneficiary

http://www.cgsmedicare.com/hhh/medreview/med_review_edits.html

Additional Document Request (ADRs)

• Check for ADRs at least once per week

ADR Quick Reference Tool

http://www.cgsmedicare.com/hhh/education/materials/pdf/ADR_QRT.pdf

Chapter 3: Inquiry Menu

http://www.cgsmedicare.com/hhh/education/materials/pdf/Chapter3_Inquiry_Menu.pdf   

ResourcesCGS

http://www.cgsmedicare.com/hhh/index.html– Frequently asked questions– Education materials (Quick Reference Tools)– Claim information– E-mail list serve

ResourcesCMS Hospice Center

http://www.cms.gov/Center/Provider-Type/Hospice-Center.html

– CMS Q&A– Change Requests and Transmittals– CMS manuals– MLN Matters Articles– Open Door Forum

Resources

Nebraska Hospice and Palliative

Care Associationnehospice.org

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