Following a trial in which a national hospice chain (AseraCare) was initially found to have submitted false claims, the Court ordered a new trial. In making this rare order, the Court acknowledged that it had failed to provide the jury with proper instructions as to required findings for a false claim, including that the government must show an “objective falsehood,” and not a mere lack of supporting evidence; and that a mere “difference of opinion” between doctors, without more, could not support a false claim finding. In the same order, the Court indicated it will reconsider granting summary judgment to the hospice and required the government to identify any evidence offered at trial that it believes would support a finding of “objective falsehood.” Continue Reading
In March 2015, CMS instructed its contractors to add sequestered funds, amounts never paid to providers, to revenue for purposes of calculating the hospice cap. This results in cap repayment demands that are overstated, in that they require repayment of funds never received. Continue Reading
On April 30, 2015, CMS released its FY 2015 Hospice Wage Index, including long anticipated payment reform and some changes to the hospice cap calculation. Comments are due by June 29. Here is an initial summary and analysis. Continue Reading
In the last few years, we have seen a growing and alarming trend of administrative law judges (“ALJ”) dismissing appeals solely based on purported lack of service to the hospice patient (the Medicare beneficiary). A search of recent decisions shows over 150 such cases at the Medicare Appeals Council starting in 2012 and continuing to the present. Administrative law judges appear to increasingly be using these grounds as a basis for dismissal. Continue Reading
As quietly promised, Medicare Administrative Contractors (NGS, Palmetto) have begun issuing FY 2013 cap demands with sequestration (money never paid) included as a part of revenue, thus overstating the demands. The demand letters themselves do not call out the sequestration adjustment. To see the increase in revenue, and thus increase in demand, hospices need to review the cap calculation table. Continue Reading
Hospices in the Palmetto regions have begun receiving FY 2013 cap demands that include sequestration (money never paid to the hospice) as a part of a cap revenue under CMS’ new policy.
Other MACs are expected to follow shortly. Continue Reading
This week, the Medicare Administrative Contractors issued instructions for hospices to self-report FY 2014 hospice cap (reports due this month, March 31, 2015). These instructions include a spreadsheet substantially similar to what we offered earlier this year. Hospices that fail to submit reports by March 31 may be subject to payment suspension until reports are completed. Continue Reading
On October 1, 2014, CMS revised its attending physician requirements, setting another potential trap for the unwary. 42 C.F.R. 418.24 [Election of Hospice].
While statute and regulation have long required both the attending physician and hospice medical director to certify initial eligibility, CMS has now tightened regulation around identification and change of attending physician. The natural result of this change will be a more stressful hospice election process for new patients and increased audit risk for hospices.
This week at an Open Door Forum, CMS finally disclosed a long-rumored plan to overstate hospice cap liability for hospices, and thereby grab more overpayments, by adding sequestered revenue to hospice revenue. For hospices, if not challenged, this will mean that revenue will be artificially inflated by approximately 1% for 2013 (and 2% for 2014 and future years) by money never paid to the hospice (i.e., money withheld through sequestration).
With the 2014 cap year just concluded, it’s time to think about the new cap calculation requirements.
Over the summer, CMS finalized its revisions to the hospice cap rule, requiring hospices beginning with cap year 2014 (just completed) to calculate and return hospice cap overpayments within a very tight window. Hospices that fail to submit this calculation and, if applicable, repayment (or repayment plan) will be subject to suspension of all reimbursement pending completion of the report/repayment.