february 2017 subscriber webinar - constant...

www.hospicefundamentals.com Hospice Fundamentals Subscriber WebinarFebruary 2017

© 2017 Hospice FundamentalsAll Rights Reserved 1

Hospice and the Letter People: Who Are They & What Do They Want?

February 2017 Subscriber Webinar

Plan for the Webinar

• Meet the 4 Faces of Medicare

• Discuss responsibilities of each & how to get information

• Consider internal knowledge & process needs related to building regulatory competency

Knowing with what you are supposed to be complying…

The First Step in Compliance



Why Do We Do What We Do?

Regulation – Actual

Regulation – MythicalRegulation – Surveyor Suggestion Regulation – Someone Else's Accreditation Standards Professional Standards Agency PolicyAgency Tradition “We’ve always done it this way.”

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The Regulations

• Are the rules that carry out a statute• Address provision of care and payment• Define the minimum requirements a provider must meet to participate in the Medicare program

• Are designed to protect consumers

As advocates for hospice care, it is important to understand what the rules say, how they are applied and, if they don’t work, how to effect change

42 CFR 418 Subparts

A. General Provision and DefinitionsB. Eligibility, Election and Duration of BenefitsC. Conditions of Participation – Patient CareD. Conditions of Participation ‐ Organizational EnvironmentE. Conditions of Participation – Removed and Reserved F. Covered Services G. Payment for Hospice CareH. Coinsurance



The Four Faces of Medicare

Centers for Medicare and Medicaid Services

CMS

Part of the US Department of Health and Human Services DHHS

Created in March 1977 to administer Medicare and Medicaid

Formerly know as the Healthcare Financing Administration HCFA

Central office CO is in Baltimore; 10 regional offices ROs around the country



CMS Responsibilities

1. Establish provider standards2. Monitor provides to assure that they are meeting

the standards and to take action if they are not3. Assure that providers are properly paid for

services provided 4. Provide a process for beneficiaries to appeal

provider decisions

Establish Provider Requirements

Promulgate regulations based on statute Rules for Part A providers are known as

– Conditions of Participation CoPs

– Conditions of Payment

The Rule Making Steps Proposed Rule Released and

Published in Federal Register

Sixty Day Comment Period

CMS Reviews Comments

Final Rule Issued with Implementation Dates

for Any Changes



The Enduring Life of a Final Rule

The final rule creates an enduring record that may be used by many parties in the future

Comments count– CMS has to read every comment and respond in the final rule

– Volume of comments is noted

– Provides an opportunity to introduce new perspectives, suggest possibility of unintended consequences and to tactfully question assumptions

State Survey Agencies

• Survey and Certification S&C works with State Agencies SAs to monitor performance via the survey process

• Certain % of providers as specified by CMS are surveyed each year or following complaints

• If deficiencies are found, SA follows up to determine if they have been corrected or not

• By law, surveys must be unannounced

Deemed Status Surveys

Surveys may also be conducted by an Accrediting Organization (AO)

“However, there is an alternative to SA surveys for demonstrating compliance with the applicable CoPs. Accreditation based on a survey by a CMS‐approved Medicare accreditation program may be used by CMS to “deem” a provider or supplier as complying with the applicable regulatory standards.“ State Operations Manual (Chapter 1)

TJC The Joint Commission

CHAP Community Health Accreditation Partner

ACHA Accreditation Commission for Healthcare



Medicare Surveys

Surveys are conducted using 1. Subparts C & D of the hospice regulations – the

COPS – and the Interpretive Guidelines – the IGs2. State Licensure Rules3. The hospice’s own policies

The CoPs apply to all patients for whom the hospice provides care regardless of payor source

State Licensure Rules

Co‐exist with the CoPs; if both address a particular area, the higher standard prevails

Are state specific and vary from state to state (a few states do not have any)

Each state has own licensure survey frequency

If relocating to a new state, be aware that new licensure rules will apply

Reading the Conditions of Participation L Tag Condition of Participation Interpretive Guidelines

L520§418.54 Condition of participation: Initial and comprehensive assessment of the patient.

Interpretive Guidelines §418.54

L521 The hospice must conduct and document in writing a patient‐specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

The comprehensive patient assessment must accurately reflect the patient’s current health status and include information to establish and monitor a plan of care. Hospices are not required to use specific forms or formats to document their initial or comprehensive assessments. They may choose to document patient specific comprehensive assessments in either written or electronic format provided the assessments are complete, readily identifiable and available in the patient’s clinical record.

Used to identify and organize deficiencies

The actual regulatory language

Guidance for surveyors and invaluable for providers. Read side‐by‐side with the CoPs

Additional Source of Sub‐Regulatory Information: The CMS On‐Line Only Manual

System



Medicare Administrative Contractors

• The MACs

• Have been also been called Regional Home Health and Hospice Intermediaries RHHIs and Fiscal Intermediaries FIs

• Contract with CMS to process Medicare claims

• By law must be non‐governmental entities

• Performance assessed regularly by CMS and Office of the Inspector General OIG

• Contractor Error Rate Testing process CERT an addition means of performance assessment

• Review and make payment decisions based on Subparts B and the Conditions of Coverage and other information found in Subpart F

§418.200 Requirements for Coverage

To be covered, hospice services must meet the following requirements. 1. They must be reasonable and necessary for the palliation or

management of the terminal illness as well as related conditions. 2. The individual must elect hospice care in accordance with Sec. 418.24. 3. A plan of care must be established and periodically reviewed by the

attending physician, the medical director, and the interdisciplinary group of the hospice program as set forth in Sec. 418.56.

4. The plan of care must be established before hospice care is provided. 5. The services provided must be consistent with the plan of care. 6. A certification that the individual is terminally ill must be completed as

set forth in Sec. 418.22.

Subpart B: The Technical Coverage Provisions

Requirements that apply to Medicare patients only–Certification– Election / Revocation–Admission / Discharge– Transfers– Eligibility



Other MAC Functions

• Provider education

• Claims review

• Hospice cap calculations

• Processing changes in provider information

• Beneficiary services

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The Hospice MACs

1. Palmetto Government Benefits Administrators PGBA

2. Cahaba Government Services CGS

3. National Government Services NGS

The Medicare QIOs• Formerly known as Peer Review Organizations, the PRO, now

known as Quality Improvement Organizations QIOs

• Non‐profits; up until 2014 re‐organizations one in each state

• Hospices interact with them when issuing a notice of Medicare Non‐Coverage NOMNC as part of the Expedited Determination Process

• Part of Beneficiary Notice Initiative BNI; information is found in Chapter 11 of the Claims Processing Manual regulations and at link below rather than with the rest of the hospice regulations

www.cms.gov/Medicare/Medicare‐General‐Information/BNI/index.html



Post-Reorganization BFCC‐QIOs

Beneficiary and Family Centered Care Quality Improvement Organizations carry out the case review function and will handle all first level beneficiary appeals resulting from hospice discharges for ineligibility.

QIN‐QIOs

Quality Innovation Network ‐Quality Improvement Organization will be responsible for working directly with providers and communities on quality initiatives. Hospices can expect to have more interactions with these in upcoming years.

A Note on Medicaid

• Medicaid hospice benefit is almost identical to HMB

• No separate provider certification process

• States have separate reporting rules

• No routine survey visits

• States may process claims themselves or work with fiscal agents

Available Resources



Medicare Internet Only Manuals • CMS program issuances, day‐to‐day operating instructions, policies, and

procedures

• Based on statutes, regulations, guidelines, models, and directives

• Used by providers, contractors, Medicare Advantage organizations and state survey agencies to administer CMS programs

• Organized by function rather than by provider

• Of most interest to hospices – Benefit Policy Manual – Chapter 9– State Operations Manual (Surveyor Interpretive Guidelines – Appendix M)– Claims Processing Manual – Chapter 11– Benefit Integrity Manual

www.cms.hhs.gov/Manuals/IOM/list.asp

CMS Program Transmittals

• Vehicle used to communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS program manual

• Cover page (or transmittal page) summarizes the change

• Each has both a transmittal and a change request number; the latter is what they are commonly referred to as

• Material ultimately added to the manual identified on transmittal page

• Medicare Learning Network will also issue an MLN Matters article on new information; usually a bit easier to understand but not always exactly correct

When Questions Arise



Next Time You Hear “Because Medicare...”

Ask yourself

– Which face of Medicare said it?

– Where and when?

– Has it been superseded?

– Are my circumstances the same or similar?

– Is there another regulatory body with which to check?

– If Medicare is silent on the topic, does my agency have a policy that addresses it?

Questions about Patient Care?

Social Security Act

Conditions of Participation

Interpretive Guideline

Medicare Internet Only Manuals

Transmittals / Change Requests

State Licensure Rules

Occupational Licensing Boards

Accreditation Standards

Agency Policies DecisionBroader Issues

Payment Question Route – Who’s Paying?

Medicare Eligibility Subpart B (sometimes F as well) Medicare Manuals Transmittals / Change Requests Check with MAC

Medicaid Eligibility Medicaid Manuals Check with State Agency

Private Insurer Contract Check with case manager or

customer service

Self Pay Agency Policy



When Addressing Questions Many questions have no black and white answer – learn to appreciate that grey gives you more room

Must establish a process if you want some measure of consistency

Reasonable people can and will disagree – don’t take it personally

Everyone should be expected to defend his/her position and back it up with evidence

Every action (or inaction) sets a precedent

Lively debate will definitely ensue

Considering New Regulations

Cracking the Regulatory Code

• History – what brought this on?

• Intent – what change is the regulation intended to make? Why?

• Supporting Rationale – if a change that is published in the Federal Register, what does the narrative say?

• Impact – who in my hospice will be impacted?

• Which face of Medicare will monitor?

• What are the risks of under‐compliance or non‐compliance?

• What would over‐compliance look like?



Building Regulatory Competence

1. Defined expectations of regulatory knowledge by position

2. Assigned responsibility for monitoring regulatory changes

3. Plan for teaching regulatory content in orientation and at regular intervals

Building Regulatory Competence

4. Plan for communicating changes at appropriate levels

5. An internal process to use when there is “no answer”

6. Ability to assess risk of any action or inaction

To Contact UsSusan Balfour919‐491‐0699

[email protected]

Roseanne Berry480‐650‐5604

[email protected]

Charlene Ross602‐740‐0783

[email protected] information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations.

Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Four Faces of Medicare

A. General Provision and DefinitionsB. Eligibility, Election and Duration of BenefitsC. Conditions of Participation – Patient CareD. Conditions of Participation - Organizational EnvironmentE. Conditions of Participation – Removed and ReservedF. Covered ServicesG. Payment for Hospice CareH. Coinsurance

visit www.hospicefundamentals.com or call us at 919-491-0699

Code of Federal RegulationsTitle 42, Volume 2, Parts 400 to 429

PART 418 — HOSPICE CARE

42 CFR 418 Subparts

Centers for Medicare & Medicaid Services

Medicare Administrative Contractors

Assure that providers are paid for services

SUBPARTS B, F & G

State Survey &Certification Agencies

Monitor providers to assure that they are meeting the standards

SUBPARTS C & D

Quality ImprovementOrganization

Provide a process for beneficiaries to appeal provider decisions

CMS BENEFICIARY NOTICE INITIATIVE

ROs

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