Federal hospice regulations must be met to participate in Medicare and Medicaid programs. When becoming a Medicare-certified hospice agency, providers agree to focus on providing quality care and protecting the health and safety of the beneficiaries they serve. While the various subparts of the federal hospice regulations serve different purposes, they all require compliant implementation and accurate documentation, as there is scrutiny of both these items during a survey or an audit.

This blog updates and summarizes recent focus medical reviews from the Medicare Administrative Contractors (MACs – CGS, Palmetto, and Noridian) to better understand the action needed for proactive approaches versus responding to document requests reactively. Staying vigilant and updated on regulatory requirements creates a foundation of compliance and quality in your agency operations and financial stability.

Let’s start with a summary of 2022 top denial reasons for the MACs

  • CGS
    • According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less
    • The notice of election is invalid because it doesn’t meet statutory/regulatory requirements
    • According to Medicare hospice requirements, the documentation indicated the general inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate.
    • Face-to-face encounter requirements not met
  • Palmetto
    • Notice of Election is invalid because it doesn’t meet statutory or regulatory requirements
    • Auto -denial- Requested records not submitted
    • Not hospice appropriate
    • Face-to-face encounter requirements not met
    • Hospice GIP reduction-services not reasonable/necessary
  • NGS
    • General hospice denial rate
    • Physician narrative statement is not present or not valid
    • No certification for dates billed
    • Face-to-face encounter requirements not met
    • Notice of election invalid as it doesn’t meet statutory/regulatory requirements.

Additional Development Requests (ADRs) are issued to review documentation for errors and inconsistencies in claims or when other documentation is needed to complete the claim. These reviews focus on various aspects of the claim, such as signatures, location of service for the beneficiaries, length of inpatient level of care days, diagnosis coding accuracy, visit notes included on claims, and more. The overall goal is to identify overpayments and protect the Medicare Trust Fund. Claims data is used to decide who may get a request, which could be a focus on number of days of service with hospice (length of stay), level of care provided, quality of physician documentation and updated requirements on the election of benefit statement.

Being proactive is the best action to prepare for an ADR, it reduces the risk of denials and saves money. Remember, being reactive is far more costly than being proactive.  A proactive stance also involves audit readiness as you perform compliance and quality monitoring of processes, and review billing compliance for continued data monitoring. One proactive step is completing a review of a clinical record before claim submission.

It is best practice to perform pre-bill claim reviews by a clinical team member, including a review of all technical elements (e.g., CTI including a review of physician narrative statement, F2F, and update POC) and medical necessity/eligibility for the entire benefit period. At a minimum, reviewing a sampling of records to identify potential risks will support a proactive approach. Monitor your PEPPER (Program for Evaluating Payment Patterns Electronic Report) reports and claims data analysis to identify trends. If your agency is not conducting clinical pre-billing reviews prior to claim submission, it is strongly recommended to add this to your next QAPI plan to help reduce risk and expense on reimbursement issues.

Be familiar with your MAC information and resources related to medical review. Knowing their process and targets for ADRs is half the battle.

Dawn B. Cheek, BSN, Director Clinical Consulting, McBee

Jennifer Kennedy, EdD, BAN, RN, CHC, VP, Quality, Standards, & Compliance, CHAP


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