Avoiding Costly Medicare Mistakes Hospice Todays Presenters Corrinne

Avoiding Costly Medicare Mistakes Hospice

Today’s Presenters § Corrinne Ball, RN, CPC, CACO Provider Outreach and Education Consultant Email: J 6. provider. training@anthem. com 2 Hospice

Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at https: //www. cms. gov. 3 Hospice

No Recording § Attendees/providers are never permitted to record (tape record or any other method) our educational events § This applies to our webinars, teleconferences, live events and any other type of National Government Services educational events 4 Hospice

Acronyms § Acronyms used in this presentation can be viewed on the NGSMedicare. com website. On the Welcome page, click on Provider Resources > Acronyms. 5 Hospice

Objectives § To provide education on top return to providers, rejections and denials for Medicare claims, and provide instructions on how providers can avoid costly mistakes when billing to Medicare. 6 Hospice

Agenda § Top three § Return to providers § Rejections § Denials § Notice of Election § Exceptional circumstances § Condition Code 85 § Transfer patients § PEPPER Reports 7 Hospice

Medicare Updates § System issues § Regulatory and Policy 8 Hospice

Denials, Rejections and RTPs 9 Hospice

Top Three Denial Reason Codes § 55 H 1 L- Terminal Prognosis not supported § 56900 – Medical Records not received timely § 55 H 1 Y- Physician narrative not present 10 Hospice

Provider Action for Reason Code 55 H 1 L § If you do not agree with the denial send a redetermination request (appeal) 11 Hospice

Tips for Preventing Reason Code 55 H 1 L § Ensure that the documentation provides clear evidence that the medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course § Documentation is KEY! 12 Hospice

Provider Action for Reason Code 56900 § If less than 120 days after denial notification on remittance advice, submit records to NGS medical review § Do NOT resubmit the claim § If records were sent - wait one week and recheck the status of the claim. If the claim moved to status location S M 5 REC- nothing more is needed 13 Hospice

Tips for Preventing Reason Code 56900 § Attach the appropriate ADR request on the top of the medical records § Providers have 45 days to return records this includes all mailing and processing time. § The system will automatically deny the claim on the 45 th day if the records are not processed by mail and distribution and move to a medical review location 14 Hospice

Provider Action for Reason Code 55 H 1 Y § If you do not agree with the decision you must file a redetermination (appeal) with National Government Services. 15 Hospice

Tips for Preventing Reason Code 55 H 1 Y § As of October 1, 2009 the physician must document a narrative which briefly explains the patients clinical findings and why they are eligible for hospice § If the physician documents see my progress note – there needs to be enough detail to indicate which progress note contains his narrative § “See Attached” – need detailed information 16 Hospice

Top Three RTP Reason Codes § 37402 - Sequential Billing § U 5106 - Open election period § U 5194 - late NOE 17 Hospice

Provider Action for Reason Code 37402 § Prior bill must be processed before resubmitting this claim § Check FISS/DDE and/or the remittance statement for finalized prior claim § Verify that the correct date(s) of service are being billed 18 Hospice

Tips for Preventing Reason Code 37402 § Verify there is no gap between the “to” date on the previous claim, and the “from” date on the next claim § Ensure that the prior claim is finalized before submitting the next claim. 19 Hospice

Provider Action for Reason Code U 5106 § Verify the notice of election (NOE) is billed with the correct admission date § If the NOE admission date is incorrect: § Cancel the NOE and resubmit § If the admission date is correct, previous election period must be closed with a final hospice claim before the NOE is submitted. 20 Hospice

Tips for Preventing Reason Code U 5106 § Check the common working file (CWF) prior to submitting the NOE to determine if an open election period exists § If an open election exists from another hospice agency, contact them to request that they finish billing in order to close the election § File a notice of termination/revocation (NOTR) within five days of the beneficiary revoking or discharging alive from the hospice benefit 21 Hospice

Provider Action for Reason Code U 5194 § Educate your staff on the five day timely filing of the notice of election (NOE) § When its not possible to timely file the NOE: § Educate staff on filing for an exceptional circumstance if appropriate § Educate staff on the appeals process for denied claims 22 Hospice

Tips for Preventing Reason Code U 5194 § Review your work flow process and procedures for filing a NOE § Verify beneficiary information at the time of admission 23 Hospice

Top Three Rejections Reason Codes § 38200 - Duplicate § 39929 - Line item denial § 38037 - Duplicate 24 Hospice

Provider Action for Reason Code 38200 § If an exact duplicate is not present, remove all rejection coding on page 6 if present and resubmit the claim § No action required if claim is exact duplicate to processed claim § Adjust original claim if additional information needs to be added to original claim § Submit a new claim if two claims were submitted at the same time and both rejected as a duplicate to each other. 25 Hospice

Tips for Preventing Reason Code 38200 § Know when to adjust a claim rather than to submit a new claim § Check internal system, processes and/or procedures § Develop and implement process to ensure duplicate claims are being submitted § Check claim submission history 26 Hospice

Provider Action for Reason Code 39929 § Check the line level rejection information § From claim page 2 press <F 11/PF 11> twice § Line level reason code will be shown in the Denial Reason field § Press <F 1/PF 1> to access the reason code file § Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative 27 Hospice

Provider Action for Reason Code 38037 § Verify the “from” and “through” dates, provider number, revenue codes, HCPCS codes, and diagnosis codes on the bill § If the claim is truly a duplicate; no action is necessary 28 Hospice

Tips for Preventing Reason Code 38037 § Know when to adjust a claim rather than submit a new claim § Adjust claims when making changes to the original processed claim § Check internal systems, processed and/or procedures § Develop and implement process to ensure duplicate claims are not being submitted 29 Hospice

Medical Review 30 Hospice

Medical Review Audits § Provider specific probes and audits § Annual percent change in reimbursement of greater than 30% § Longer length of stay § Increased average use of GIP § High percentage of patients reside in a NF/SNF as compared to peers § Wide spread probes § None at this time 31 Hospice

Medical Review Top Three Denials § 55 H 1 L- Terminal Prognosis not supported § 55 H 1 Y-Physician narrative not present or not valid § 55 H 1 K- No documents to support billed services 32 Hospice

Provider Action for Reason Code 55 H 1 K § Documentation was not received to support the services billed. You will need to submit an appeal. 33 Hospice

Tips for Preventing Reason Code 55 H 1 K § Develop quality process to check documentation prior to sending § Documentation needs to support all services billed • Nursing visits • Aid visits • Social Worker visits • Level of service billed 34 Hospice

Notice of Election Timely Filing Exceptions 35 Hospice

Four Exceptions for Untimely Filed NOE 1. fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate; 2. an event that produces a data filing problem due to a CMS or A/B MAC (HHH) systems issue that is beyond the control of the hospice; 3. a newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its A/B MAC (HHH); or, 4. other circumstances determined by the A/B MAC (HHH) or CMS to be beyond the control of the hospice. 36 Hospice

Fields on an NOE § To request an late filed NOE exceptional circumstance § Occurrence span code 77 with the dates the NOE was late § Modifier KX on the first line item only that contains the Qcode § Remarks- Enter remarks to substantiate why the NOE met an exceptional circumstance § File an appeal if you receive an unfavorable decision do NOT resubmit or adjust the claim 37 Hospice

Transfers 38 Hospice

Hospice Transfers § Patient may change hospices once in each benefit period § Patient must file a transfer statement with original hospice and newly designated hospice § Must include the name of the hospice from which the patient received care, the name of the hospice from which they plan to receive care, and the date the change is to be effective § Transfer effective date can occur on same date as the discharge from previous agency or the next day § Both the transferring hospice and receiving agency may bill for the day of transfer 39 Hospice

Hospice Transfers § TOB: 81 C/82 C § Notifies contractor and CWF that the admission is a continuation of the current hospice election period § The notice of change can only be submitted after the agency the beneficiary is transferring from has submitted their final claim § Submitted by the hospice agency the beneficiary is transferring to prior to submitting their first claim Step-by-step guidance is provided in the Hospice Transfers Job Aid 40 Hospice

How To Transfer a Beneficiary 41 Hospice

• Communication • Signed election statement Preparation • • Paper work • Billing Fax to receiving hospice: Transfer agreement Election statement Face-to-Face Physician Certifications • Hospice A finalize claims • Hospice B submits 81 C or 82 C 42 Hospice

When Transferring a Patient § Do NOT § Send the receiving hospice all paper work related to the transfer § File an NOTR § Include an occurrence code 42 • This will terminate the benefit period § File billing as quickly as possible • New agency cannot file an 8 XC until your billing is complete § xx § Notify the receiving hospice when discharge claim has been processed 43 Hospice

When Receiving a beneficiary § Do NOT § Review all documentation received for completeness and accuracy § Submit an 8 XC until the previous hospice has completed all billing § If NOE, physician certification or FTF (if applicable) is not valid § Submit a claim until the 8 XC has processed and finalized • Complete a new paper on admission § Submit 8 XC only after the previous hospice has completed their billing 44 Hospice

Condition Code 85 45 Hospice

Condition Code 85 § Effective January 1, 2017 § Used in conjunction with OSC 77 and OC 27 to identify a late physician certification 46 Hospice

PEPPER Reports 47 Hospice

FRAUD § Found Routinely After Using Data 48 Hospice

Headlines in the News § Doctors convicted in $8. 8 million Medicare hospice fraud (May 5, 2016) § “lying about patients' terminally ill status in order to refer them to a hospice facility and submit roughly $8. 8 million in fraudulent Medicare and Medi-Cal claims” § No Witness Needed for Conviction in $9. 5 Million Hospice Fraud (June 13, 2016) § … “Improper billing of hospice services at an elevated level of care, ” § Minnesota-based Hospice Provider to Pay $18 Million for Alleged False Claims to Medicare for patients Who Were Not Terminally Ill. (July 13, 2016) 49 Hospice

OIG Reports § Hospices Inappropriately billed Medicare Over $250 Million for General Inpatient Care 03 -302016 Report (OEI-02 -10 -00491) § Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities Report (OEI-02 -14 -00070) 50 Hospice

Hospice PEPPER Reports Accessed by State Percent of hospices that accessed PEPPER in the state: 80 -100% 60 -79% 40 -59% 20 -39% 0 -19% Hospice

What is a PEPPER Report? § Program for Evaluating Payment Patterns Electronic Report § Data report that contains a single hospice’s claims data statistics § Compares an individual provider data statistics to: § State data § Jurisdiction date § National data § Guide for auditing & monitoring 52 Hospice

Benefits of a PEPPER Report § Identify potential areas of aberrancy when compared to other hospices in your state, jurisdiction and nationally. 53 Hospice

PEPPER Report § Provided by TMF Health Quality Institute § Target areas were identified based on: § Review of the Medicare hospice benefit § Analysis of claims data § Coordination with CMS subject matter experts. § PEPPER does not identify improper payments 54 Hospice

www. pepperresources. org Hospice

PEPPER Training & Resources Hospice

www. peppersource. org Hospice

www. peppersource. org Hospice

CERT A/B MAC Outreach & Education Task Force 59 Hospice

CERT A/B MAC Outreach & Education Task Force § The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. § A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. § Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions § Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate. 60 Hospice

CERT A/B MAC Outreach & Education Task Force § CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force § CMS has a web page dedicated to education developed by the CERT A/B MAC Outreach & Education Task Force • https: //www. cms. gov/Medicare. Contracting/FFSProv. Cust. Svc. Gen/CERT-Outreach-and-Education-Task. Force. html § NGS CERT Task Force Web Page § Go to our website, https: //www. NGSMedicare. com; in the About Me drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page. 61 Hospice

Email Updates § Subscribe to receive the latest Medicare information. 62 Hospice

Website Survey § This is your chance to have your voice heard— click on “Yes, I’ll give feedback” when you see this pop-up so NGS can make your job easier! 63 Hospice

Medicare University § Interactive online system available 24/7 § Educational opportunities available § Computer-based training courses § Teleconferences, webinars, live seminars/face-to-face training § Self-report attendance § Website § http: //www. Medicare. University. com 64 Hospice

Medicare University Self-Reporting Instructions § Log on to National Government Services’ Medicare University § http: //www. Medicare. University. com • • Topic = Enter title of webinar Medicare University Credits (MUCs) = Enter number Catalog Number = To be provided Course Code = To be provided § Visit our website for step-by-step self-reporting instructions. • Click on the Education tab, then the Medicare University Course List tab, click on the Get Credit link. This will open the Get Credit for Completed Courses web page. 65 Hospice

Continuing Education Credits § All National Government Services Part A and Part B Provider Outreach and Education attendees can now receive one CEU from AAPC for every hour of National Government Services education received. § If you are accredited with a professional organization other than AAPC, and you plan to request continuing education credit, please contact your organization not National Government Services with your questions concerning CEUs. 66 Hospice

Thank You! § Follow-up email § Attendees will be provided a Medicare University Course Code § Questions? 67 Hospice