Recently, one of Weatherbee’s senior consultants observed a hospice’s interdisciplinary group (IDG) meeting as part of an on-site mock survey of the organization. The 4-hour meeting included a review of all deaths and admissions that occurred during the prior 2 weeks, as well as a review of all existing patients on the hospice’s census. A total of 30 patients were discussed. The medical director, 4 registered nurses (RNs), 2 social workers, a chaplain, and the volunteer coordinator were present during the meeting.

In the midst of tremendous challenges facing the hospice industry, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) that is likely to have a positive effect on hospice providers.  The guidance from CMS directs MAC and QIC reviewers to limit the redetermination and reconsideration review to the reason(s) the claim was initially denied for all post-payment reviews.

Don’t shoot the messenger but compliance with Medicare and Medicaid rules just got tougher for hospice organizations.  In the first judicial opinion on when a Medicare or Medicaid “Overpayment” is “identified” for purposes of the Affordable Care Act’s (ACA) 60-Day Repayment Law, a New York federal court’s interpretation complicates the already difficult task providers face in having sufficient time to assess and quantify potential overpayments. 

I have been thinking a lot about the FY 2016  Hospice Wage Index proposed rule (NPRM).  The more I have thought about it, however, the more complex it seems. I have needed to harken back to my salami methodology (described here) and try to break it down into manageable chunks. The only chunks I am focusing on are the ones having to do with payment reform (tiered reimbursement and the Service Intensity Add-On) and the "clarification" to include all diagnoses on claim forms (and the related - excuse the pun - virtually all / related and not related / prognosis vs diagnosis conundrums).

Last year, a hospice medical director in Pennsylvania, was convicted of Medicare fraud for false certifications of the clinical eligibility of patients for hospice care. The wrongdoing involved appears to be fairly black and white.  However, another more nuanced area of regulatory oversight of physicians is looming on the horizon. 

I had not been paying much attention to NHPCO's flurry of activity during March regarding prognosis vs. diagnosis until I received an email from a well-respected hospice CEO that said, in part: 

"Our Medical Director is livid and is adamant that what 'influences' the prognosis is very different from what is "related to" the prognosis.  This seems like a fundamental shift from what we have been doing for thirty years - is it possible that everyone (including NHPCO) has been so wrong about this? We think we have financial challenges now - just wait!"

One of my favorite nuns in high school often called me "bold" (a frequent nun term) and accused me of taking too much pleasure in "starting revolutions."  For this blog post, allow me to be bold and describe a revolution I see occurring in the hospice industry.  I did not start it, I don't even take pleasure in it - but I want to name it.

The evaluation and policy division of the HHS Office of Inspector General (OIG) issued a study dated January 13, 2015 after evaluating all Medicare hospice claims from 2007 through 2012.  If history is a guide, critical OIG studies such as this one trigger additional targeted scrutiny, and so hospices, particularly for-profit hospices, should expect increased hospice audits related to their services to ALF residents. 

Years of experience and research have demonstrated that “…people learn, and organizations change most readily when they focus on, study, and engage in dialogue about strengths, patterns of success and who they are at their best."

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