Archive for the ‘Hospice’ Category

OIG Posts Video Guidance on Self-Disclosure

Authored By: David W. Bufford

As part of their on-going video series, the Office of Inspector General (OIG) has posted a video on their self-disclosure protocols.

Self-disclosure is a key element of an effective compliance program, and can possibly reduce any civil monetary penalties (CMPs) associated with a violation or instance of noncompliance.

The OIG has provided many videos in this series that are beneficial for long-term care providers. The full list of videos is available on the OIG Website.

Should you have any questions, please contact:
Todd Selby at 317.977.1440 or tselby@hallrender.com;
Brian Jent at 317.977.1402 or bjent@hallrender.com; or
David Bufford at 502.568.9368 or dbufford@hallrender.com,
or your regular Hall Render attorney.

Changes to Hospice Discharge Coding Coming this Summer

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) has published a transmittal detailing changes for coding hospice discharges, which will provide greater clarity as to why the patient has been discharged from hospice care. (more…)

CMS Updates MSN for Hospice Services

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) has responded to criticism detailing how Medicare contractors present hospice service charges in the Medicare Summary Notice (MSN) to beneficiaries. In recent years, CMS has added new reporting requirements for visit data on hospice claims. This resulted in an expansion of the information of the claim record to better understand the services provided under the hospice benefit. However, the new data cause confusion for Medicare beneficiaries when they reviewed their MSN.

Effective July 1, 2012, with an implementation date of July 2, 2012, CMS will revise the presentation of hospice cost charges on the MSN. The revised MSN will be similar to the home health MSN and more accurately reflect the claim data.

This change should reduce beneficiary confusion and present the hospice claim data more clearly. Visit-charge descriptions will inform beneficiaries that the hospice service charge is included in the payment for the hospice daily level of care. This will alleviate the perception of some hospice beneficiaries that they will be billed individually for covered services.

CMS Clarifies Guidance on PPACA Mandatory Medicaid Terminations

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) released updated guidance on Section 6501 of the Patient Protection and Affordable Care Act (PPACA) that requires state Medicaid agencies to terminate the participation of any individual or entity if such individual or entity is terminated under Medicare or any other state Medicaid plan. (more…)

OIG Releases Provider Compliance Videos

Authored By: David W. Bufford

In December, the Office of the Inspector General (OIG) released an initial series of videos aimed at providers that focus on compliance issues. These videos are part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative. Health & Human Services Inspector General Daniel Levinson stated the videos are intended to help providers further enhance their compliance efforts. (more…)

Nursing Home’s Failure to Notify Leaves Beneficiary Not Liable for Custodial Care Services

Authored By: David W. Bufford

A Medicare beneficiary is not liable for custodial care services rendered by a Mississippi nursing home because the facility failed to give adequate notice the services were not covered by Medicare, a federal appeals court panel ruled on October 25. The case (Mississippi Care Center of Morton LLC, Sebelius, 5th Cir., No. 10-60595, Oct. 25, 2011) concerned the application of 42 C.F.R. 411.404, which states a beneficiary is considered to have known custodial care or services that are not reasonable and necessary are not covered services under Medicare, provided the beneficiary received adequate notice the services are not covered under Medicare. (more…)

Medicare Provider Revalidation Requests

Authored By: Brian D. Jent

The Centers for Medicare & Medicaid Services has posted a list of providers who have been sent a request to revalidate their Medicare enrollment information. You can access and review the list, then select “Revalidation Phase 1 Listing.” The list will be updated monthly and providers are encouraged to review the list. If you are listed but have not received the request, contact your Medicare Administrative Contractor. Please note that revalidation applications are due sixty (60) days from the date of the request.

If you have questions or concerns regarding the foregoing or would like additional information, please contact your regular Hall Render attorney, or Todd Selby at tselby@hallrender.com or 317.977.1440; Brian Jent at bjent@hallrender.com or 317.977.1402; or David Bufford at dbufford@hallrender.com or 502.568.9368.

CMS Extends Timeline for Provider Revalidation

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (“CMS”) has reevaluated the revalidation requirements in the Affordable Care Act (“ACA”), and believe the ACA allows for the extension of the revalidation period for an additional two years. This will extend the deadline for revalidation through March of 2015. Providers are reminded that if they have already received their notice to revalidate, they must complete the revalidation within the original time-frame. This only will extend the time-frame CMS has to issue the revalidation notices. This also does not affect the screening category certain providers or suppliers are assigned for revalidation.

Hospice Owner Indicted for $14.3 Million in False Claims

Authored By: Todd J. Selby

On October 12, 2011, the U.S. Department of Justice unsealed an indictment charging Matthew Kolodesh a/k/a Matvei Kolodech, with conspiracy to defraud Medicare of more than $14 million. According to the indictment, Kolodesh’s business, Home Care Hospice, Inc. (HCH), located in Philadelphia, PA, submitted Medicare claims for approximately $14.3 million dollars for patients who were ineligible for hospice benefits or who did not receive any services.

Some of the ineligible patients were not terminally ill and were on service in excess of six months. At the direction of Kolodesh, HCH staff was instructed to alter patients’ charts to document a patient’s medical condition as worse than it actually was. HCH staff was also instructed to bill claims at a higher, costlier rate of service than what was provided to the patient.

In February 2007, HCH was notified that is was the subject of a claims review audit. Again, A.P. and Kolodesh directed staff to falsify documentation that was to be submitted for the audit. In September 2007, HCH was notified it has exceeded the cap for Medicare reimbursement and would have to repay $2,625,047 to the Medicare program. At that time, A.P. and Kolodesh initiated a mass discharge program of the ineligible and inappropriately maintained hospice patients.

If convicted, Kolodesh faces a statutory maximum sentence of 370 year in prison and will owe Medicare approximately $14.3 million. The case was investigated by the Federal Bureau of Investigation and the Department of Health and Human Services Office of Inspector General. It is being prosecuted by the U.S. Attorney’s Office, Eastern District, Pennsylvania.

While this is a very egregious example of an attempt to defraud the Medicare program, having ineligible hospice patients on service or unusually long lengths of stay are precisely the types of activities the Medicare Administrative Contractor will review when conducting a claim audit. The lesson learned is that if you defraud the Medicare program you will get caught.

If you have questions please contact:

Todd Selby at 317.977.1440 or tselby@hallrender.com;
Brian Jent at 317.977.1402 or bjent@hallrender.com; or
David Bufford at 502.568.9368 or dbufford@hallrender.com, or your regular Hall Render attorney.

CMS Updates Claims Processing Manual to Reflect Failure of Timely Hospice Face-to-Face

Authored By: David W. Bufford

As previously discussed, hospice providers are required to have a hospice physician or nurse practitioner perform a face-to-face encounter with each hospice patient whose total length of stay is anticipated to reach the third benefit period. This encounter must be performed no more than thirty days prior to the third benefit period recertification, and no more than thirty days prior to any subsequent recertification.

CMS has just released Transmital 2316 which updates the Claims Processing Manual to reflect the failure of a hospice to complete a timely face-to-face evaluation. Such a failure will result in the beneficiary no longer being considered terminally ill for Medicare purposes due to lack of recertification. As patients receiving a hospice benefit must be certified as terminally ill, no longer being considered terminally ill renders the patient ineligible for the Medicare hospice benefit. (more…)

OIG Publishes 2012 Work Plan

Authored By: Todd J. Selby

On October 5, 2011, the Office of Inspector General (OIG) published its proposed Work Plan for Fiscal Year 2012. As in the past, the Work Plan continues to identify compliance risk areas that subject Medicare and Medicaid providers to audit and enforcement initiatives. The 2012 Work Plan contains several new areas of focus by the OIG that potentially will impact current operating practices of nursing homes and hospices and the relationships between these types of providers. More specifically, areas of increased scrutiny are (i) nursing home compliance plans; (ii) billing patterns of Part B provider services during non-Part A nursing home stays; and (iii) hospice marketing practices and financial relationships with nursing facilities.

The OIG will review Medicare- and Medicaid-certified nursing homes to ensure the implementation of compliance plans as a part of their day-to-day operations. The compliance plans will be reviewed to ensure they contain the required elements of the OIG’s compliance program guidance. Under the Affordable Care Act, nursing facilities must operate a compliance and ethics program to prevent and detect criminal, civil and administrative violations and to promote quality of care. The Centers for Medicare & Medicaid Services (CMS) is charged with overseeing the program and incorporating the requirements into the Medicare Requirements of Participation. CMS also must issue regulations by 2012, and nursing facility providers must have compliance programs in place by 2013.

Billing patterns of nursing facilities and Medicare Part B providers will be scrutinized to confirm that services provided by Part B providers to nursing facility residents during a non-Part A stay are billed directly by suppliers and providers. More particularly, the OIG will analyze podiatry, ambulance, laboratory and imaging services for conformity with this requirement.

Lastly, the OIG will closely examine and monitor hospices’ marketing materials and practices and their financial relationships with nursing facilities. Recently, the OIG reported that a high percentage of hospice claims for services to Medicare Part A-eligible nursing facility beneficiaries did not meet the Medicare coverage requirements. Observations by MedPAC, an independent congressional agency that advises Congress on issues affecting Medicare, suggest that hospices and nursing facilities may be involved in inappropriate enrollment and compensation relationships. Consequently, practices of hospices with a high percentage of their patients in nursing facilities will undergo increased inspection as well as those hospices that aggressively market their services to nursing facility residents.

A complete copy of the 2012 Work Plan can be accessed at http://www.oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf

Update on NLRB Actions

Authored By: David W. Bufford

As Mr. Lyman pointed out last week, the National Labor Relations Board (NLRB) now requires private employers to post a Notice of Employee Rights under the National Labor Relations Act (NLRA). A recent New York Times article on this new requirement discusses an upcoming decision by the NLRB that is expected to address unionization of long-term care employees specifically. Any developments concerning this decision will be included in a future posting as they become available.

Should you have any questions, please contact:

Steve Lyman at 317.633.4884 or slyman@hallrender.com;
Todd Selby at 317.977.1440 or tselby@hallrender.com;
Brian Jent at 317.977.1402 or bjent@hallrender.com; or
David Bufford at 502.568.9368 or dbufford@hallrender.com, or your regular Hall Render attorney.

NLRB Notice Requirement Affects Long-Term Care Providers

Authored By: Stephen Lyman

The National Labor Relations Board (NLRB) just issued a final rule that will require most private employers, including those that are long-term care providers, to post a Notice of Employee Rights under the National Labor Relations Act (NLRA). The notices must be posted by November 14, 2011. The text of the notice is available in the final rule (starting on page 185), however this is not the final form of the notice. (more…)

Revised CMS-855 Forms Published, New CMS-855O to Order and Refer Items

Authored By: David W. Bufford

The US Office of Management and Budget has approved the revised Medicare Provider-Supplier Enrollment Applications, the CMS-855 forms. These updates to the 2008 versions include multiple changes to comply with enhanced disclosure requirements. Such changes include: (more…)

CMS Home Health, Hospice & Durable Medical Equipment Forum Today at 2 p.m. EST.

Authored By: David W. Bufford

The proposed agenda for today’s Home Health, Hospice & DME/Quality Open Door Forum is as follows: Hospice wage index final rule published; Hospice CR 7518 with FY 2012 updated rates and cap amount issued; Timeline for Hospice CAP changes; HHCAHPS Updates. This is scheduled for Wednesday, August 17, 2011 from 2:00pm-3:00pm EST.

Resistration for this Open Door Forum is available here.

What Risk Categories Mean to Providers and Suppliers

Authored By: David W. Bufford

Earlier this week, we highlighted the implementation by Centers for Medicare & Medicaid Services (CMS) of enrollment revalidations and screening categories, and which categories CMS places certain long-term care providers. It is important for providers and suppliers to understand what each screening category (limited, moderate, or high) entails and be aware of any events which could elevate screening categories. While these posts focus on long-term care providers, the enrollment revalidations and screening categorizations are applicable to all Medicare providers and suppliers. (more…)

Update to Revalidation Enrollment Procedures

Authored By: Todd J. Selby

As an update to the previous post on the revalidation enrollment procedures it is important for hospices, home health agencies, and DMEPOS to know what level of screening they will receive from the Medicare Administrative Contractor (“MAC”). In some instances these providers and suppliers will be screened at either a “high” or “moderate” level of risk by the MAC. The risk category assigned corresponds with the amount of possible fraud and abuse that CMS believes is applicable to providers and suppliers.

All hospices (current and newly enrolled) will be screened at a “moderate” level of risk. Newly enrolling home health agencies will be screened at a “high” level of risk. The only other “high” category is newly enrolling DMEPOS. DMEPOS or home health agencies that are publicly traded on the NYSE or NASDAQ are classified as “limited” risk. Currently enrolled home health agencies and DMEPOS will be screened at a “moderate” level of risk.

It is VERY important that currently and newly enrolled hospices, home health agencies and DMEPOS accurately complete the revalidation process when completing the applicable CMS Form 855 due to the level of screening it will receive from the MAC. It is also VERY important to know that the CMS Form 855 has recently changed and requires, in some instances, much more detailed information. For example, the providers are required to provide much more detail on its ownership and operating structure.

Should you have questions on the revalidation process or the new CMS Form 855, please contact Todd Selby at 317.977.1440 or tselby@hallrender.com, Brian Jent at 317.977.1402 or bjent@hallrender.com, David Bufford at 502.568.9368 or dbufford@hallrender.com, or your regular Hall Render attorney.

Medicare Providers and Suppliers Must Begin Enrollment Revalidations

Authored By: David W. Bufford

As of March 2011, the Centers for Medicare & Medicaid Services (CMS) implemented new screening criteria in the Medicare provider/supplier enrollment process. Newly enrolling and revalidating providers and suppliers are placed in one of three categories – limited, moderate, or high – each representing the level of risk to the Medicare program for that provider’s/supplier’s particular category. The categorization will determine the degree of scrutiny the Medicare Administrative Contractor (MAC) will utilize when screening the enrollment application. (more…)

Providers Should Anticipate Reimbursement Changes in Debt Ceiling Agreement

Authored By: David W. Bufford

While Congress was able to present the President with a compromised solution to cut Federal spending and raise the Government’s debt ceiling earlier this month, all long-term care providers should anticipate future reimbursement changes. Under the current law, the Budget Control Act of 2011, Medicare and Medicaid are unchanged. However, the Act requires for the creation of a Joint Select Committee on Deficit Reduction, whose members have until November 23rd of this year to find $1.5 trillion in spending cuts. (more…)

In FY 2012: Medicare Hospice Wage Index Increases 2.5%, Other Hospice Changes

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) increased fiscal year (FY) 2012 Medicare payments by 2.5% for hospice providers in a final regulation released July 29. Also included in the final regulation are requirements for hospice providers to start collecting quality of care data and changes to the way CMS counts hospice patients for the 2012 cap accounting year.

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OIG: Expand Oversight and Reduce Incentives to Hospices Focusing on Nursing Facility Residents

Authored By: Kendra Conover

Recently, the Office of Inspector General (“OIG”) published a report of its findings pertaining to the nearly 70% growth of Medicare spending for hospice care provided to nursing facility (“NF”) residents from 2005 – 2009. During that time, Medicare spending on hospice care for residents in NFs increased sixty-nine percent (69%) from $2.55 billion to $4.31 billion; while the number of NF residents receiving Medicare-funded hospice care increased only by forty percent (40%). In its report, the OIG informally designated hospices with more than 2/3 of their patients residing in NFs as “high-percentage hospices.” This report comes on the tail of the Medicare Payment Advisory Commission (“MedPAC”) 2009 report to Congress that hospices and NFs may be involved in inappropriate enrollment and compensation.

The OIG recommended to the Centers for Medicare and Medicaid Services (“CMS”) that CMS: (1) Monitor hospices that depend heavily on NF residents and (2) Modify the payment system for hospice care in NFs. CMS concurred with both of OIG’s recommendations. CMS stated it will share the information with Recovery Audit Contractors (“RAC”), who review Medicare claims on a post-payment basis to identify inappropriate payments, and Medicare Administrative Contractors (“MAC”) to monitor high percentage hospices. CMS further stated it is in the early stages of reform efforts for the payment system that may be currently and unintentionally be incentivizing hospices to seek out beneficiaries in NFs.

Clearly, this July 2011 report is neither the beginning nor end of the scrutiny over high-percentage hospices and CMS has indicated changes in payment for hospice care to NF residents are on the horizon. The OIG’s report, the first in a series, focuses on the OIG’s and MedPac’s increasing concerns pertaining to the relationships between hospices, especially for-profit hospice providers, and NFs. The OIG plans to look at and later release companion reports on the marketing practices of these hospices and their business relationship with NFs. Enforcement activity is anticipated to increase.

Given these trends and the OIG’s and CMS’ increased scrutiny of these high percentage hospice’s business practices – namely involving marketing and patient enrollment – hospices and NFs should exercise extreme vigilance to ensure compliance with all of the rules and regulations governing Medicare reimbursement.

If you have any questions regarding this OIG report, please contact your regular Hall Render attorney, or Todd Selby at tselby@hallrender.com or 317.977.1440, or Kendra Conover at kconover@hallrender.com or 317.977.1456.

Michigan Begins Medicaid Estate Recovery

Authored By: Sean J. Fahey

Michigan’s Department of Community Health will enforce Michigan’s Medicaid Asset Recovery Act (MCL Sec. 400.112g) with efforts starting July 1, 2011. Michigan may file claims in the probate estates of individuals age 55 or older who received Medicaid benefits that paid for long term care services after September 30, 2007. Michigan’s claim would seek reimbursement for the expenses paid by Michigan for the deceased individual’s long term care services. Michigan may also file claims in the probate estates of the surviving spouse of a Medicaid recipient.

Michigan will likely seek recovery from an estate if an individual owned a residence that was exempt from Medicaid requirements when the individual applied for and qualified for Medicaid benefits. When a Medicaid beneficiary age 55 or older dies, Michigan will send an estate recovery notice to the estate’s representative or heirs. The estate recovery notice will tell them that Michigan plans to file a claim and how much Michigan will claim. Some exceptions and hardship waivers are available to avoid Michigan’s recovery of assets in some circumstances. Michigan has contracted with Health Management Services, Inc. to pursue Michigan’s estate recovery claims.

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Hospice Contracts With Assisted Living Facilities

Authored By: Todd J. Selby

When the new hospice Conditions of Participation (CoPs) became effective in Decmeber of 2008 there was a provision in the CoPs stating a hospice must have an agreement with a nursing home if the hospice provides services in the nursing home. While it was a standard business practice for hospices to have agreements with nursing homes prior to enactment of the CoPs, the CoPs were specific as to what must be included in the agreement.

One of the questions we continue to get is whether a hospice is required to have an agreement with an assisted living facility (“ALF”)? Legally speaking there is no requirment for the hospice to have an agreement with an ALF. Practically speaking we believe it is a good idea.

From a legal perspective CMS stated, in commentary to the CoPs, that a hospice is only required to have agreements with nursing homes that participate in either Medicare and/or Medicaid and ICFs/MR. The rationale of CMS was that ALFs are not Medicare-certified and therefore do not receive Medicare funding which would exempt them from the CoP requiring an agreement. Therefore, there is no legal obligation for a hospice to have an agreement with an ALF.

From a practical perspective, we generally advise that a hospice have an agreement with an ALF. First of all, it is good business practice that defines the role of the hospice and the ALF in the provision of hospice services. Another good reason for an agreement is that many states license ALFs and the applicable state regulations may require an agreement. Finally, since the same surveyors often times conduct surveys in both nursing homes and ALFs, it can avoid confusion by the surveyors over whether an agreement is required.

Should you have questions, please contact Todd Selby at 317.977.1440 or tselby@hallrender.com, Brian Jent at 317.977.1402 or bjent@hallrender.com, David Bufford at 502.568.9368 or dbufford@hallrender.com, or your regular Hall Render attorney.

Updates to Hospice Face-to-Face Encounters

Authored By: Todd J. Selby

In response to the changes contained in the Patient Protection and Affordable Care Act (ACA) designed to address increasing lengths of stay in hospice programs, CMS added a “face-to-face encounter” requirement to the hospice certification requirements.

Effective January 1, 2011, a hospice physician or nurse practitioner must have a “face-to-face” encounter with each hospice patient whose total length of stay is anticipated to reach the third benefit period. This encounter must be performed no more than thirty days prior to the third benefit period recertification, and no more than thirty days prior to any subsequent recertification.

CMS recently provided two answers addressing billable physician and nurse practitioner visits concurrent with the required face-to-face encounter. (more…)

Indiana Enacts Uniform Adult Guardianship and Protective Proceedings Act

Authored By: Sean J. Fahey

Indiana recently enacted the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act (the “Act”). The Act is effective July 1, 2011, and is designed to eliminate multi-state jurisdictional issues and “Granny snatching” cases. The Act is located in Indiana Code 29-3.5.

Typically, the fact pattern arises when (1) an Indiana older adult resident visits a child in another state (Ohio) for vacation, or (2) a child comes to Indiana, grabs Mom and takes her to the home (Ohio) of the visiting children in a state other than Indiana. Frequently, the misconduct is designed to financially exploit the parent and deprive the Indiana courts of jurisdiction, as the parent’s home state. Such actions by the child are intended to take the parent out of the reach of an Indiana guardianship. If the receiving state (Ohio) has adopted the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act, attorneys can rely upon the new Indiana statute.

Also, adult guardianships have increasingly become more complex due to jurisdictional issues. For instance, imagine an elderly adult who owns property in more than one state or the circumstance where an incapacitated adult needs to be moved from one state to another for medical or financial reasons. Which state has jurisdiction? (more…)

Archive for the ‘Hospice’ Category

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