We have approached the time of the year to address the self-reporting of your Hospice Aggregate Cap. For this year, the aggregate Capmust be submitted by February 28, 2025, and will cover the fiscal year ending on September 30, 2024.
Remember that the reports used for self-reporting must be downloaded from the system at least three months after the fiscal year ends, which means no earlier than December 31.
These reports will be used to complete the aggregate Cap reporting for each of your Medicare MACs: Palmetto GBA, CGS, and NGS. Each has specific formats available on their websites, along with detailed instructions for proper completion.
The calculation involves counting the unique beneficiaries treated during the fiscal year and determining the Cap limit for that year, which was just over $34,000. This is then used to assess whether your Medicare payments exceeded your Cap calculation. If they did, you will owe money and should make the repayment at the time of self-reporting. There are options available, such as requesting an extended repayment plan, particularly for substantial amounts.
Many questions arise about the $34,000 limit, like whether it’s per patient, per year, or per lifetime. The answer is that it’s per patient, but over their lifetime. For example, if a patient received Hospice services for two years, the $34,000 would be divided between those years. This means you would count that patient as half a beneficiary for each year they were on service.
If you’ve already self-reported for the first year and are now in the second year with the same patient for the full year, you will count them as half a beneficiary when completing your aggregate Cap self-report. When Medicare audits your self-reporting, they will reopen the previous year’s report and adjust it to give you credit for half a beneficiary. This applies regardless of whether the patient was with your Hospice or a different one in the first year. If they were with another Hospice, Medicare will reopen that Hospice’s report and recalculate based on the updated beneficiary count.
Hospices often exceed their CAP calculation when they have a large number of long-term patients. For example, if you have 10 patients, with eight on service for over a year and two on service for about six months, you’re likely to face Cap issues. This is because you won’t receive the full $34,000 credit for patients who have already been on service in prior years. It’s important to balance long-term and short-term patients. While some long-term cases are unexpected at admission, they do happen. To avoid Cap issues, you need to offset these with short-term patients to maintain financial stability.
Over the past 25 years, it’s been unsettling to see how many hospices have faced Cap issues in recent years. The total number is likely much higher than imagined. The key is balancing long-term patients with short-term ones. If you have a significant number of long-term patients, it’s worth asking whether they truly met Hospice eligibility criteria at the time of admission.
Returning to the topic of Cap self-reporting, be sure to visit your Medicare MAC’s website to access their preferred reporting forms. Ensure that your report is officially submitted and received by the Medicare MAC no later than February 28. Failure to do so could result in your payments being withheld, as they will stop processing claims if they have not received your self-reported Cap.
If Healthcare Provider Solutions can assist with any of your Hospice needs, please don’t hesitate to reach out to us.
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