Category Archives: Hospice Law

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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

Hospice to Provide “Virtually All” Care – First Up, Prescription Drugs

A hospice patient waives the right to receive other Medicare benefits “related” to the terminal illness.  In turn, the hospice must provide any care necessary for “pain or symptom relief.”  Focusing upon this waiver/assumption of liability, CMS is now redefining the scope of a hospice’s duty, requiring hospices to pay for “virtually all” prescription drugs … Continue Reading

‘Tis The Season for Hospice Probe Edits – Be Ready

Palmetto GBA has announced a new non-cancer prepayment edit targeted at hospices with significant nursing home populations.  Many providers have been through similar non-cancer probe edits repeatedly, while for others this may be a new experience.  In this post, Sheppard Mullin reviews several important points for providers facing such edits (from any Medicare Administrative Contractor).… Continue Reading

Hospice Face 2 Face Audit Update

Effective April 2011, CMS implemented the Affordable Care Act requirement that hospices conduct a face to face visit as part of any recertification of any beneficiary in the third or later benefit period.  With the forthcoming hospice and home health RAC auditor, hospices will face increasing audits on face to face compliance.  In this post, … Continue Reading

A Review of CMS’ Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present Beneficiaries

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present).  In this post, Sheppard Mullin examines the recovery process CMS has put in place, noting CMS procedural shortcomings and reviewing some substantive defenses available to providers facing such demands.… Continue Reading

Hospice Cap Calculation Update

Beginning in June 2012, CMS contractors began calculating and issuing hospice cap repayment demands for FY 2010 and 2011.  Hospices that have not filed appeals previously have the choice either before or after receiving the demand to select one of two calculation methods – either the old “Streamlined” method or the new “Pro Rated” method.  … Continue Reading

Hospice Cap: Past, Present, and Future

On May 10, 2013, Brian Daucher presented “Hospice Cap: Past, Present, and Future” to the Mumms Hospice Innovation Conference (presentation) in New Orleans, Louisiana.  The presentation covers history of the hospice cap, the hospice cap litigation, the new pro-rated hospice cap calculation method, comparison of the two available methods, and tools and advice for hospices … Continue Reading

ZPIC/RAC/ADR Appeals Deadline Desk Calendar

The attached table identifies each level of appeal available to providers facing either pre- or post-payment claims denials, whether through ADR edits, probe edits, Zone Program Integrity Contractors, or RAC auditors.  The table identifies deadlines to file appeals of initial or revised determinations at each level and also provides tips to help ensure that appeals are … Continue Reading

ZPIC/RAC Audits – What You Need To Know

On February 26, 2013, Brian Daucher and Dolly Curley (Simione Healthcare Consultants) presented “ZPIC / RAC Audits – What You Need To Know” to the American Health Lawyers Association Annual Meeting for Long Term Care and the Law Conference (presentation) in Austin, Texas.  The presentation covers the structure and operational characteristics of Zone Program Integrity … Continue Reading

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