By now you have hopefully heard about the changes regarding the hospice Notice of Election (NOE), Notice of Termination/Revocation (NOTR), and processes for identifying/changing the attending physician that take effect October 1, 2014. This blog post details these changes and identifies best practices to comply with the changes. At the conclusion of this post is a downloadable PDF that you can share with everyone who needs this information.
The Medicare Hospice Benefit (MHB) requires that each beneficiary or patient intentionally choose hospice care. This patient choice is documented in the NOE. The hospice cannot provide any services or bill for days of care before the effective date the NOE is signed.
Beginning October 1, 2014, The NOE must include:
- Identification of the hospice
- Acknowledgement of the palliative versus curative care
- Medicare waiver for services related to the terminal illness and related conditions
- Date of election
- Signature of beneficiary / representative
- Name of the patient’s attending physician
- Acknowledgment that the identified attending physician was the patient’s / representative’s choice
The MHB also requires that a hospice use a NOTR, also known by its type of bill (8XB), to communicate to the Medicare Administrative Contractor (MAC) that a beneficiary has been discharged alive or revoked the Medicare Hospice Benefit within 5 calendar days, unless a final bill has been submitted. The NOTR contains the same data elements as the NOE and is entered via Direct Data Entry (DDE).
Filing the NOE
- Beginning October 1, 2014 the NOE must be submitted to the Medicare Administrative Contractor (MAC) within 5 calendar days.
- When a patient elects hospice, either as a new admission or a transfer from another hospice, the hospice must complete multiple form locators (FL) of the Uniform Bill (Form CMS-1450), which is the election notice.
- This election, Form CMS-1450) is sent to the MAC by mail, messenger, or DDE.
- If a patient is admitted to hospice before the month that he/she is eligible for Medicare (e.g., before age 65), then an NOE is not submitted. If the patient is still receiving hospice services on the first day of the month he/she turns 65, then the NOE must be signed and submitted within five days of the first of that month.
If a NOE is not submitted and received by the MAC within 5 calendar days, the hospice is financially liable for all care from the date of election until the date the NOE is filed. If the NOE is late, the hospice cannot bill for any days of care provided prior to the date the NOE is filed.
CMS has provided for the following exceptions to the timely filing requirements:
- Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate
- CMS or MAC system filing issues beyond the control of the hospice
- A newly Medicare-certified hospice that is either:
- Notified of that certification after the Medicare certification date or
- Awaiting its user ID from its MAC
- Other circumstances determined by CMS to be beyond the control of the hospice
In order to be approved for an exception, the hospice must document the circumstances to support the request for an untimely NOE exception and submit that to the MAC. The MAC will determine if the exceptional circumstance qualifies for an untimely NOE filing exception.
CMS also stated that the following will NOT be allowed as exceptions for timely filing of the NOE:
- Personnel issues
- Internal IT issues
- Not knowing the requirements
- Failure of the hospice to have back-up staff to file the NOE
Filing the NOTR
- Beginning October 1, 2014 the hospice must submit a NOTR within 5 calendar days of the discharge or revocation, unless a final hospice claim has been filed
- There is no need to file a NOTR when a patient dies
- Unlike the NOE, there is currently no penalty or consequence if a hospice files the NOTR late
Best Practices for Filing the NOE/NOTR
- File the NOE/NOTR as soon as possible after the election, just in case there is a problem with the submission. Don’t wait until the 5th day
- Establish contingency plans to ensure adequate coverage for administrative staff that normally file the NOE/NOTR and cross train staff regarding the entire NOE/NOTR process
- Evaluate your hospice’s internal process for NOE completion and notifying the MAC of a beneficiary’s election to ensure the timely submission of the NOE
Patient Designation of Attending Physician
The Social Security Act (at 1861(dd)(3)(B)) defines the hospice attending physician as, “The physician or nurse practitioner, who may be employed by a hospice program, whom the individual identifies as having the most significant role in the determination and delivery of medical care to the individual at the time the individual makes an election to receive hospice care.” Under Patient’s Rights (§ 418.52(c)(4)), The Hospice Conditions of Participation states that the hospice patient has the right to choose his/her attending physician.
- Effective October 1, 2014 the Notice of Election must include the name of the attending physician the patient / representative has chosen
- The NOE must also include a mechanism for the patient / representative to acknowledge that the identified attending physician listed on the NOE was his / her choice
- Each hospice must develop a Change in Attending Form, which must be signed by the patient / representative
- The Change in Attending form must include:
- Physician’s full name
- Office address
- NPI number
- Date change is to be effective (effective date can be no earlier than the date the form is signed)
- Date statement is signed
- Patient / representative’s signature
- Acknowledgement that the change is the patient’s / representative’s choice
- If the physician is unable or unwilling to serve as the patient’s attending physician, that must be documented in the patient’s clinical record and the patient / representative must be informed that they may choose another attending physician; including a physician or nurse practitioner from the hospice or the community
Compliance Risks Associated with the Designation of the Attending Physician
The following practices could lead to survey deficiencies and/or a non-compliance audit:
- Automatically changing the patient’ attending physician when a patient moves to an inpatient setting for the General Inpatient (GIP) level of care
- “Assigning” an attending physician based on physician availability, rather than documented patient/representative choice
- Failure to obtain the attending physician’s signature on the initial certification
Best Practices Regarding the Patient Designation of the Attending Physician
- Modify the NOE to include the name of the attending physician and language that affirms the choice of the attending physician was made by the patient / representative.
- Develop a process regarding how to explain the challenges involved when a hospitalist is selected to be the attending by the patient / representative
- Determine where in the clinical record changes regarding the attending physician will be documented, including information about the new attending physician
Federal Register Final Rule (August 22, 2014)
- Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election. This CR rescinds and fully replaces CR 8777
- Election of Hospice: A Compliance Guide for Hospice Providers (NHPCO members-only)
The Hospice Regulatory Boot Camp includes comprehensive training on these and recent changes to the regulations. Register for one of the two remaining 2014 trainings.
Download a PDF of this blog to share with others within your organization.
Posted by: Carrie Cooley, RN, MSN, Director, Consulting Division