Healthcare Provider Solutions

Over the last few weeks there have been updates that hospice should be aware of:  the 2017 Final Rule has been issued and Medicare MACs have finally acknowledged that the new payment rates for Routine Home Care and the Service Intensity Add-On have not been paid correctly in all situations since January 1, 2016.

The key highlights from the 2017 Hospice Wage Index and Rate Update include:

  • Full Implementation of the updated CBSA codes/areas.
  • Hospice base payment rates will increase by 2.1%, an increase of 0.1% over what was projected in the proposed rule.  The 0.1% differential is due to changes in the hospital market basket value and the productivity adjustment
  • Following are the base payment rates that CMS is finalizing for FY2017: These values assume compliance with quality reporting requirements and do NOT include the 2% sequester, which is scheduled to continue for several more years.

  • Following are the hospice Cap values as calculated by CMS:
    • o    2016 Cap:  $27,820.75 (2016 Cap year runs from 11/01/15-10/31/16)
    • o    2017 Cap:  $28,404.99 (2017 Cap year runs from 10/01/16-09/30/17)

CMS Finalized:

  • Two new hospice quality reporting program (HQRP) measures:

1.    Hospice Visits When Death is Imminent– assessing hospice staff visits to patients and caregivers in the last week of life; and
2.    Hospice and Palliative Care Composite Process Measure– assessing the percentage of hospice patients who received care processes consistent with existing guidelines

  • Codification at §418.312 that if the National Quality Forum (NQF) makes only non-substantive changes to specifications for HQRP measures in the NQF’s re-endorsement process CMS would continue to utilize the measure in its new endorsed status.
  • Hospices receiving their CCN after January 1, 2017, are exempt from the FY 2019 APU Hospice CAHPS® requirements due to newness.   Hospices receiving their CCN after January 1, 2018, are exempted from the FY 2020 APU Hospice CAHPS® requirements due to newness.

Many more changes:  LEARN MORE

Hospice had some significant changes in payment structure that went into effect January 1, 2016. There have been payment discrepancies identified and following are updates from the Medicare MACs regarding these adjustments.  Agencies need to be confirming payments when received and tracking the ones that are not paid correctly initially so that when they are corrected the agency can insure that all were paid correctly.

CMS Hospice Update on Incorrect Payments Identified for the Two Tier Payment and SIA Payments

Situation:  Effective January 1, 2016, two separate payment rates replaced the single Routine Home Care (RHC) rate:

1.    A higher RHC rate for days 1 through 60; and
2.    A lower RHC rate for days 61 and beyond.

An issue has been identified with the two separate payment rates for RHC services on and after January 1, 2016. On some claims, the high rate is populating on the claim for the RHC days when the low rate should have been applied.

Impact to Provider:  Overpayments have occurred on certain claims.

Status:  8/12/2016 – Two recent systems issues caused routine home care days to be miscounted on hospice claims:

  • Systems were not counting days that should receive high routine home care payments if a revocation was posted on the benefit period before the final claim was submitted. A correction was implemented on May 9, 2016.
  • Systems were using the election date instead of the admission date when a prior hospice period was involved. A correction was implemented on July 25, 2016.

Medicare Administrative Contactors are adjusting hospice claims to correct payment for dates of service on or after January 1, 2016. All adjustments to correct these two problems shall be completed in the next 90 days. Hospices do not need to take any action.

Service Intensity Add-On (SIA) Payment
Issue: In certain situations, the Medicare system is not applying the end-of-life (EOL) service intensity add-on (SIA) payment to the previous month’s claim, when a patient dies within the first few days of a month. The Medicare system is designed to trigger an automatic adjustment of the prior month’s claim if the prior month’s claim is eligible for the SIA payment. This adjustment will apply the EOL SIA amounts to the previous claim that could not be identified in the initial processing. These adjustments are not occurring on the prior months claim in the following situations:

  • When the incoming claim does not contain a qualifying RHC service;
  • When the provider adjusts the original claim to add qualifying (or additional) RN and/or MSW visits;
  • When the provider adjusts the IUR (32G) claim that originally applied the SIA payment, the adjustment claim removes all EOL SIA payments.

CMS is aware of the issue and the MACs anticipate instructions from CMS in the January 2017 release to correct the Medicare system issue.

Provider Action: Currently there is no provider action to be taken. Providers do not need to submit an adjustment claim for the previous month, nor does the provider need to submit an appeal. This is a Medicare system issue.