Category Archives: Hospice Law

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CMS Plans To Reopen Cap Demands Forever

In recent weeks, hospice providers have been receiving revised cap demands for fiscal years 2012 and earlier.  Although the initial demands in these cases were issued more than three years earlier, CMS now claims that it can reopen and revise cap demands for up to three years from the most recent demand.  Based upon this … Continue Reading

Hospice Cap Calculation Changes

Traditionally, the cap accounting year has ended October 31, putting the cap accounting year one month off of the Federal government fiscal year.   In May 2015, CMS proposed to adjust the cap accounting year to end September 30 to align with the Federal government fiscal year.  This transition will occur in 2017. To change the accounting … Continue Reading

CMS Issues Suggested Notice Of Election Statement

Following an OIG report on election statements in September, CMS has posted a suggested, but not mandatory, notice of election statement. From inception of the benefit, hospices have been required to formulate their own notice of election.  Regulations require only that the election statement: (a) identify the hospice; (b) identify the attending physician chosen by the … Continue Reading

ZPICs Terrorize, Close Hospices; CMS Blesses Approach

In recent months, ZPICs, tiring of the post-payment audit due process constraints imposed by Congress, have begun utilizing devastating and unlawful tools to put hospices, and presumably other providers, out of business – full payment suspension and full prepayment audit.  CMS has now reviewed and blessed this conduct. In the case of a longstanding Puerto … Continue Reading

OIG Issues Report On Hospice Election Statements

On September 16, 2016, the Office of Investigator General for CMS issued a report on hospice election statements, concluding that many of the statements in use by hospices are deficient in some respect.  In its review of 565 election statements, OIG concluded that 35 percent were deficient in some manner. Hospice patients are required to … Continue Reading

CMS Proposes ALJ Hearing Changes

As most hospice providers know all too well, CMS faces an ever growing backlog of ALJ cases.  This backlog stems in large part from aggressive audit procedures employed by ZPICs, RACs, and MACs that issue sweeping numbers of pre- and post-payment denials, often on less than substantive or meritorious grounds, leading to more appeals.… Continue Reading

Hospice Payment Changes Take Effect

With the advent of the 2016 (Happy New Year!), hospices now face the revised hospice payment system. Specifically, Medicare will pay a higher routine home care rate for the first 60 days of care ($187 average) and a lower routine home care rate for days beyond 60 ($147 average).  These adjustments are supposed to be … Continue Reading

Hospice False Claims Case Helps Clarify Law

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 … Continue Reading

Hospice Cap Sequestration Update

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

ALJ Now Dismissing Hospice Appeals For Allegedly Insufficient Service On Beneficiary

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 … Continue Reading

Sequestration Adjustments To Hospice Cap – See Examples

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 … Continue Reading

Hospices To Self-Report Cap Without Sequestration; MACs To Capture Sequestration Later

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

Attending Physician Documentation Changes Increase Audit Risk

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 … Continue Reading

CMS Plans To Add Sequestration Dollars To Hospice Cap

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 … Continue Reading

New CMS Hospice Item Set Reporting Invades Privacy Rights

For admissions on and after July 1, 2014, CMS will require hospices to file detailed reports (link) for every patient served including every type of personal information (social security number, full name, Medicare HICN, DNR detail, and details about the terminal illness and treatment).  While there are many aspects of this reporting requirement that have … Continue Reading

Notes from AHLA Presentation on Post Payment Audits

On February 20, 2014, Brian Daucher and Claudia Reingruber (Reingruber & Assoicates) presented “Medicare Post Payment Audits (RACs, ZPICs, and Other Tools)” to the American Health Lawyers Association Annual Meeting for Long Term Care and the Law Conference (presentation) in Las Vegas, Nevada.  The presentation covers the structure and operational characteristics of Zone Program Integrity … Continue Reading

Notes On Increasing Acute and Post-Acute Integration

The focus of the AHLA Long Term Care Conference was on convergence of acute (hospital) and post-acute (SNF, home health, hospice) service delivery mechanisms. A number of forces promote this convergence including: Accountable care organizations forming integrated delivery systems including doctors, hospitals, and post-acute services; Growth of exchange based insurance alliances that limit post-acute choices … Continue Reading

MEDPac’s View of the Hospice Benefit: December Meeting Update

MEDPac recently published the transcript of its December 2013 meeting where a number of hospice issues were discussed, including: (a) payment update/adequacy (recommending – no payment update for 2015); and (b) potential integration of the hospice benefit into Medicare Advantage plans (recommending integration by 2017).  Here are some notes on the meeting.… Continue Reading
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