Delta Connect Blog

CMS Eases Scope of PA for Part D Beneficiaries on Hospice: Limits PA to 4 Drug Categories Identified by OIG as a Concern

Posted by Lorraine Lodigiani on Jul 22, 2014 8:00:26 AM

On July 18, 2014 the Centers for Medicare & Medicaid Services (CMS) released a memorandum, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice, which updates the guidance previously released in March.  Under the new guidance, in lieu of placing a beneficiary-level prior authorization (PA) on all drugs for beneficiaries who have elected hospice, CMS strongly encourages Part D sponsors to place beneficiary-level PA requirements on only four categories of prescription drugs: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics).

Drugs prescribed for hospice patients under these four categories and paid for under Part D were the subject of a 2012 Office of the Inspector General (OIG) report in which concerns were raised that Medicare may be paying twice for drugs for hospice patients -- once under the bundled hospice per diem that includes drugs that are prescribed for the terminal diagnosis and related conditions and again under Part D.

In the memo, CMS conveys that it expects that medications in these four drug classes will rarely be unrelated to the patient’s principal terminal diagnosis and related conditions so hospice will be paying for these medications most of the time.  While CMS indicates that the change is effective immediately and strongly encourages plans to implement the guidance as soon as possible, plans MUST implement the guidance by until Oct. 1, 2014.

Requirements under the previous guidance - across-the-board PA for drugs processed by Part D for hospice patients - resulted in significant problems for patients and their families in accessing needed medications, as well as for hospice providers and Part D plans.  On June 25 CMS officials met with a wide array of stakeholders, including representatives of the National Association for Home Care & Hospice, who documented these problems.  The issue also generated widespread media attention and engagement of members from both houses of Congress. 

In the July 18 memo, CMS  points out that hospice providers should note that there are drugs that are statutorily excluded from the Part D benefit, including drugs for the symptomatic relief of cough and cold, most prescription vitamins, and nonprescription (i.e., OTC) drugs. In order to lessen beneficiary confusion, hospices should avoid referring beneficiaries to their Part D plan/pharmacy for coverage for these medications.

While the Part D-hospice coordination PA requirement is lifted for drugs that do not fall under the 4 categories of drugs identified in the memo, drugs prescribed for beneficiaries who have elected the hospice benefit that are unrelated to the terminal illness and related conditions continue to be subject to standard Part D formulary management practices, including quantity limitations, step therapy, and prior authorization that have been approved by CMS.

This new guidance replaces previous guidance and is in effect until something more permanent is identified.  This means the guidance is just that – guidance.  Part D plans are still able to develop their own policies, procedures, and forms for the PA for hospice beneficiary medications. 

This is a continuing concern for NAHC and we strongly encourage providers to share information with us about problems that arise under which patients are unable to receive Part D-covered medications in a timely manner. Please send information to eithertmf@nahc.orgor, and put “Part D/Hospice Coordination” in the subject line.

A summary of the key changes in the guidance is below.

There are some changes that should expedite the patient receiving his/her medications. The Part D plans are encouraged to accept information directly from the hospices.  Specifically, the Part D plan should not wait for the beneficiary, beneficiary’s representative, or the prescriber to formally request a determination. If a claim has been rejected by a sponsor due to the beneficiary-level hospice PA, the pharmacy or beneficiary may contact the hospice provider for a statement that the drug is unrelated to the terminal illness and related conditions. The hospice provider should contact the Part D sponsor to provide an oral or written statement or provide a written statement to the pharmacy or the beneficiary to transmit to the Part D sponsor. The sponsor should accept this information to override the point of sale (POS) reject without requiring that the beneficiary, or others on their behalf, request a coverage determination. When the beneficiary, the beneficiary’s appointed representative or the prescriber requests a coverage determination, the sponsor should contact either the prescriber or the hospice provider and accept and use the statement that the drug is unrelated to the terminal illness and/or related conditions provided by either the prescriber or hospice.

Likewise, hospice providers are encouraged to report a beneficiary’s Medicare hospice election to the Part D sponsor and identify any drugs in the four categories determined to be coverable under Part D because the drugs are unrelated to the terminal illness and/or related conditions prior to the submission of a claim.   

The documentation that a medication is unrelated no longer must include a detailed statement of the clinical reasons why the medication is unrelated.  Instead a simple statement which could be “U” or “unrelated” is to be accepted by the Part D plan in order to provide the medication to the patient.  However, the hospice should still have clearly documented the reason(s) the medication is unrelated in the patient’s medical record.  Consistent with the guidance set forth above, Part D sponsors should accept the prescriber’s or hospice provider’s statement and retain the documentation.

CMS is strongly encouraging hospice providers to supply a compassionate “first fill” for any medication needed by a beneficiary who is experiencing difficulty in accessing the drug at POS.   If the drug provided is unrelated to the terminal illness and related conditions, the hospice provider should contact the Part D sponsor to negotiate recovery of the hospice’s payment to the pharmacy at a later date.

CMS is also encouraging use of a standardized formwhich should be accepted by all Part D plans.  This form replaces the list of data elements previously identified by CMS for a PA.  The first page of the form captures the information necessary for the prior authorization of drugs in the four categories; the second page captures information on drugs related to the terminal illness and/or related conditions and specifies whether each of these drugs is the responsibility of the hospice or beneficiary. The form provides space for a rationale to support the drug is unrelated; however, no clinical justification for that determination is necessary. While hospice providers are not required to complete the second page of the form, should they choose to complete it, the information will assist sponsors in care coordination activities. Although CMS encourages Part D sponsors and hospice providers to use this two-page form, sponsors should not require its use. As long as the necessary statement that the drug is unrelated is provided, the sponsors should accept it in any format.

CMS does not expect Part D sponsors to retrospectively review paid claims for drugs outside of the four categories specifically for the purpose of determining whether the drugs were unrelated to the hospice beneficiary’s terminal illness and related conditions.  However, all Part D retrospective review requirements continue to apply to these claims.  It is unclear how CMS or the Part D plans may choose to review/pursue this in the future.

NAHC is updating its “Part D Toolkit” and those revisions should be available to member hospices in the very near future.  NAHC is also developing a list of questions related to the revised process for submission to CMS to gain greater clarity on certain aspects of the revised process.  For more on NAHC's reaction to CMS' easing of PA requirements, please see NAHC Report, July 18, 2014.

From the NAHC Report article


Read More

Topics: Hospice

Entrepeneur Profiles Home Care Franchisee Owner

Posted by Rachel Alden on Jul 17, 2014 10:26:58 AM

Today, Entrepeneur posted another installment in its "Franchise Players" interview column. This post focuses on the story of Ken Kuck, a Syngery HomeCare franchisee owner.

A few excerpts from the Q&A are included below:

Why did you choose this particular franchise?

One of my responsibilities in my old career was to look for new business opportunities. About two years before I left, I researched the in-home care industry. When it came time to venture out on my own, I looked back into it and was shocked to learn how fast the industry had grown in such a short amount of time. I eventually chose Synergy HomeCare due to its experience in the industry, excellent reputation and room to expand our business with available territory.

What advice do you have for individuals who want to own their own franchise?

Make sure you research the franchisor you wish to engage with. This is a long-term commitment and you want to make sure that their goals, values and experience are in-line with your personal goals and objectives. There are some great opportunities out there with the right franchisor. Make sure you take the time to call on offices already in their network and be prepared to ask detailed questions about their experience in the network.  

For the full article, click here.


Read More

Topics: Private Duty industry

NAHC and HHNA Announce Finalists for Home Care & Hospice Nurse of the Year Award

Posted by Lorraine Lodigiani on Jul 17, 2014 10:01:25 AM

The National Association for Home Care & Hospice (NAHC) and its affiliate Home Healthcare Nurses Association (HHNA) recently announced the top 10 finalists for Home Care & Hospice Nurse of the Year. Now NAHC and HHNA invite their members, affiliated state associations, and the general public to visit NAHC’s website and vote for this year’s winner. The 2014 Home Care & Hospice Nurse of the Year will be announced at the NAHC Annual Meeting & Exposition on October 19 - 22, 2014 at the Phoenix Convention Center in Phoenix, Arizona.
When the meeting convenes, the top nurse and nine final contenders will come before NAHC members and get the recognition they deserve. “It is most appropriate that we make the effort to identify and celebrate the best among us, the nurses who distinguish themselves by the size of their hearts, by their professionalism, and by their work ethic,” said Andrea L. Devoti, RN, chairman of the NAHC board of directors. “Our focus is to highlight the impact that nurses make day in and day out in homes across the country, despite the challenges they face,” she explained. “And it’s time for the public to honor nurses and thank them for all they contribute,” added Elaine D. Stephens, RN, NAHC executive Vice President and current chairman of HHNA. “This is our chance to remind everyone how hard it is for nurses to do their vital work while facing senseless cuts in reimbursement.”

Nurses have also faced challenges from new rules and regulations since HHNA joined NAHC in launching the Nurse Recognition Program. Yet they have continued to give patients their best, and the program pays tribute to their dedication. Now in its third year, the Nurse Recognition Program identifies the top home care and hospice nurses in the nation. This year, as always, the competition was fierce because HHNA received numerous nominations for nurses who provide exceptional care, reduce hospital readmissions, and make a difference in patients’ lives.
An expert committee chose 50 state winners, and narrowed them down to 10 top contenders, based on an essay about each nurse and thoughtful evaluation of their credentials. These 50 state nurses are featured in CARING online and will be invited to the NAHC Annual Meeting. Their registration fees will be waived, and they will be honored at a reception. The top 10 contenders will receive a $70 gift certificate from Hopkins Medical Products, now marking 70 years in business. The one who is chosen Home Care & Hospice Nurse of the Year will have their travel and hotel expenses paid, and receive a new Apple iPad along with a $140 gift certificate from Hopkins Medical Products.

The winner will also serve as a symbol of what nurses can do, and we need you to help pick this special nurse. To view the top 10 honorees, click here. Cast your vote for one of these 10 nurses who inspire us by their commitment to patients and love for their work.
“Love is the essence of nursing,” said NAHC President Val J. Halamandaris. “Nurses truly are angels of mercy; they make the difference between life and death on a daily basis.” Millions of patients depend on them today, and they will be even more needed in years to come.

From the NAHC Report article  and image from 


Read More

Topics: NAHC Annual Conference

CMS Hosts Home Health, Hospice and DME Open Door Forum

Posted by Lorraine Lodigiani on Jul 11, 2014 8:54:42 AM

The Centers for Medicare & Medicaid Services (CMS) held its most recent Home Health, Hospice, and Durable Medical Equipment (DME) Open Door Forum (ODF) on July 9, 2014.  CMS officials discussed the 2015 proposed rule for the home health prospective payment system (HHPPS), hospice reporting of DME items and the hospice CAHPS survey. Access to the recorded Forum is available through CMS’ Encore system by dialing 1-855-859-2056 and using conference ID code 44430036 beginning at 5 p.m. Eastern on July 9; the recording expires after 2 business days.

The proposed rule for the HHPPS rate update for 2015 went on display June 2, 2014 and includes both payment and non-payment related changes.

CMS proposes the following changes and clarifications to the Face to Face requirement:

  • Eliminate the narrative requirement
  • Only consider medical records from the patient’s certifying physician or discharging facility in determining initial eligibility for the Medicare home health benefit.
  • Claims for physician certification/re-certification for home health services be considered a non-covered service if the HHA claim was non-covered because the patient was ineligible for the home health benefit.
  • The proposed rule also clarifies that a new F2F encounter document must be completed when ever a start of care OASIS assessment is required, even if there has not been more than 60 days between episodes.

The proposed rate updates for Calendar year 2015 (CY) include the continuing phase in of the rebasing adjustments set out in the 2014 HHPPS rule. In addition, the 2.6 % market basket rate update will be decreased by .4% to equal 2.2% market basket update.  The .4 % decrease reflects the required productivity adjustment.

CMS proposes to recalibrated the case mix weights for 2015 using 2013 data, and  recalculate the home health wage index using the Office of Management and Budget newly delineated core based statistical areas(CBSA). For CY 2015, the wage index will be 50/50 blend of the 2014 and the 2015 wage index.

The proposed rule outlines a plan that sets a threshold for the quality reporting program. Agencies will be required to submit 70 % of OASIS quality assessments beginning July1, 2015 –June 30, 2106 in order to receive the full annual payment update for 2017. CMS will increase the threshold by 10 % for the each year until a 90% percent threshold is reach. A value based purchasing model is proposed to potentially begin in 2016. The plan would include a payment increase or reduction of 5-8 % and apply to all HHAs in each of 5-8 states selected to participate.  Lastly, the proposed rule includes changes to the Conditions of Participation for speech language pathologist qualifications.

Although the CMS officials did not comment on the provision addressing coverage of insulin injections, CMS is proposing to require that agencies list a diagnosis on the claim that supports why the patient is unable to self inject for those patients receiving home health services for the sole purpose of insulin injections. A list of acceptable diagnoses has been proposed for which CMS is seeking comments.


There were several question posed regarding the face-to-face documentation requirement. 

One was whether, with the proposal to eliminate the physician narrative requirement and have the documentation supporting the need for home health and the homebound status be in the hospital notes/physician notes, would CMS require the home health agency to have this documentation right away or would it be alright for the home health agency to request it upon receipt of an ADR.  CMS claimed they could not provide further clarification while the comment period for n the proposed rule was open, but encouraged providers to use the comment period as an opportunity to submit comments related to the provisions in the proposed rule.

Another face to face-related question was, if the proposed elimination of the physician narrative requirement were to come to fruition, how would this impact medical review?  What instructions would be given to the MACs?  CMS did not have answer but did indicate this issue has been brought up and they are looking into it.

Summary of Hospice Topics

Hospice Reporting of DME Items

Since April 1, 2014 hospices have been required to report certain drugs and equipment on the hospice claim.  Some of the claims are being returned to provider (RTP’d) in error.  These erroneous returns have reason code W7061 or W7072 and are occurring on claims including infusion pump data.  CMS is in the process of providing instruction to the Medicare administrative contractors (MACs) that will authorize MACs to override the edits so the claims will be processed.  The overrides will be applied automatically so there will be no corrective action required of hospices.  This instruction should be issued shortly per CMS.  Hospices should check their MAC’s websites for implementation dates as these may vary by MAC.  During the question and answer portion of the call, CMS indicated that hospices are free to make their own determination about whether to submit claims in the interim without the infusion pump data and then submit an adjusted claim when the corrective override is in place or hold the claims until the override is in place.   

Hospice CAHPS

The hospice CAHPS website will launch later this week and will have an address  CMS suggest hospices visit the site on Friday or Monday.  There providers will find a copy of the final hospice CAHPS survey instrument as well as the vendor minimum business requirements.  Potential vendors will be able to download participation forms which can be filled out beginning next week.  CMS has scheduled hospice CAHPS vendor training for early October.  Questions about hospice CAHPS can be submitted to


A caller representing eleven hospice facilities shared concerns about hospice termination (revocation/discharge) and hospice election information not being current and accurate in the CWF and the issues this causes for hospices, especially related to the determination of which benefit period the patient is in and the face to face encounter requirement.  The same caller stressed the horrific time patients are having in getting their medications when they’ve revoked or been discharged from hospice but the Medicare system does not contain this information. The caller shared that even though the hospices are providing the discharge/revocation paperwork to the Part D sponsors the sponsors are not accepting the documentation and are still requiring the patient to go through the Part D prior authorization process.  CMs responded that the Medicare Part D folks have received a number of reports of these types of issues and encouraged the caller to submit concerns via the ODF mailbox so the questions could be submitted to the proper department.  The address suggested by CMS staff on the call for submitting questions and concerns

PLEASE NOTE:  Questions and comments about the Part D prior authorization process may also be submitted directly to; please include “Hospice” in the subject line to ensure prompt referral of the email to the correct subject matter expert.

Several callers asked questions about the Hospice CAHPS.  CMS responded that the protocols and guidelines for the hospice CAHPS survey will not be available when the website goes live this week but are expected to be available by September, as is the list of approved vendors.  The final survey instrument has 47 questions which include demographic questions for both patients and the person answering the questionnaire.  Some questions apply only for certain settings so it is anticipated that most responders will be answering fewer than 47 questions.

There was a question regarding the additional drug and equipment reporting requirements (Change Request 8358).  Specifically, there appears to be a problem with revenue code 0291 and the corresponding HCPCS code.  Providers are being told by MACs to remove the HCPCS code and then resubmit the claim but this fix is not working.  There may be a problem with the J code that is used on this claim line.  On some of these types of claims providers are receiving the claim with reason code 33206.  CMS is checking into this but did indicate that the HCPCS code is required on the claim. 

PLEASE NOTE:  It is NAHC/HAA’s understanding that all the MACs are experiencing issues with claims that include certain HCPCS codes; as these issues arise the MACs are working to address their internal systems issues that are keeping claims from processing properly.  Please see previous NAHC Report coverage of these issues here.

In response to a question about the possibility of the physician narrative requirement being eliminated for the hospice face to face encounter documentation requirements, CMS indicated that if this were to occur a proposal is necessary and no such proposal has been made at this time.

The next scheduled Home Health, Hospice and Durable Medical Equipment Open Door Forum is scheduled for August 20, 2014.

From the NAHC Report article


Read More

Topics: CMS Open Door Forum

Hospice Data Tells the Real Story in Rebuttal to Recent Horror Stories

Posted by Lorraine Lodigiani on Jul 8, 2014 3:49:42 PM

Contributing to a string of stories about questionable business practices by "big business hospice" is the Huffington Post article  "Hospice, Inc." of June 19, 2014. This and other articles, such as a June 26, 2014 article in the Washington Post, all tell a story, but they do not tell the story.

It's deeply disappointing when these unfortunate experiences receive national exposure that casts a shadow on the overwhelmingly positive value and service hospice care brings to individuals, to their families, and to the healthcare system. Without argument, there are instances of overly-aggressive marketing, unsound business practices, and other issues in hospice, but national data strongly suggest these are the exceptions and not the rule.

According to current data received directly from over 36,000 family members that completed a standardized 56+ item evaluation of care survey, and reported by Strategic Healthcare Programs' (SHP) national hospice benchmark database, over 70% of families rate the care the patient received as "Excellent". Families said that hospices provided the right amount of emotional support before and after the patient's death 94% and 91% of the time, respectively. Quality of care is also rated high, with families saying that hospices provide "just the right" amount of medication, help with breathing, and help with anxiety and sadness 95%, 94%, and 90% of the time, respectively.


While the Huffington Post article highlighted some national statistics showing that patients are spending a longer time in hospice, a deeper look into the numbers reveals that almost half of terminally ill patients (48.5%) enter hospice within the last two weeks of their lives. 61.4% of patients are on service less than 30 days, and 35.6% are on service less than eight days. In other words, almost two-thirds of patients are not entering hospice soon enough.

Hospice LOSThe last six months of life can also be very expensive, and hospice helps reduce the financial burden on families and on society. Most of a person's healthcare costs are spent in the last few months of life, and those costs come not from hospice, but from inpatient hospital care. 

In a landmark study conducted by Duke University in 2007, the authors found that hospice reduced Medicare costs by an average of $2,309 per hospice patient, and that figure is likely higher now. The study found that Medicare costs would be reduced for seven out of ten hospice recipients if hospice had been used for a longer period of time.

"Given that hospice has been widely demonstrated to improve quality of life of patients and families…the Medicare program appears to have a [perfect] situation whereby something that improves quality of life also appears to reduce costs," writes lead author Don H. Taylor, Jr., assistant professor of public policy at Duke's Sanford Institute of Public Policy.

In a follow-up study by Amy S. Kelley, MD, MSHS, from the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mt. Sinai and published in the March 2013 issue of Health Affairs, the authors suggest that investment in the Medicare Hospice Benefit translates into savings overall for the Medicare system. "If 1,000 additional beneficiaries enrolled in hospice 15 to 30 days prior to death, Medicare could save more than $6.4 million," they note. 

The study also reveals that savings to Medicare are present for both cancer patients and non-cancer patients. Moreover, these savings appear to grow as the period of hospice enrollment lengthens with the observed study period of one to 105 days.

To bring public transparency to hospice care, the Centers for Medicare and Medicaid Services (CMS) has recently mandated a national hospice quality reporting program, HQRP, that if not complied with results in a 2% reduction in reimbursement. The new hospice measures, known as the Hospice Item Set (HIS), will begin July 1, 2014, and will cover processes of care essential to hospice. 

Next year, a new family evaluation of care survey will also be mandated, and scores and benchmarks will be made publicly available.

On June 23, 2014, David Casarett, a physician actively involved in hospice care, authored a response to the Huffington Post article, suggesting that consumers ask 15 key questions when shopping for the best hospice service in their area. One of those questions is "Do you measure and improve the quality of care that you provide to your patients?" He cautions that any hospice that doesn't have a quick and clear answer for this question probably isn't serious about patient care, and we agree. 

There are thousands of hospices that have been measuring quality data for decades, even before the recently mandated Centers for Medicare & Medicaid Services (CMS) Hospice Item Set (HIS), and they will be able to easily answer this question. Soon, consumers will also be able to compare quality scores on their own using the CMS website.

The National Association for Home Care and Hospice (NAHC) has long called for more frequent inspections or surveys of hospices. Read their response here.

The last six months of a terminally ill person's life are too often filled with physical and emotional distress for the patient and family, as well as significant financial and personal burdens. Hospice care — well-known and widely accepted in Europe, dating back to the 11th Century, and growing in the US — brings compassion and dignity to patients and families, provides physical and emotional comfort. 

Our country would do well to identify appropriate patients and admit them to hospice sooner in an effort to reduce costs to our healthcare system. The value, success, and personal impact of hospice care will not make headlines as readily as the tragic cases, but hospices will continue to do what they have been doing for centuries — provide comfort and support to those nearing the end of life and to those who love them.

Barbara Rosenblum is the Founder and CEO of Strategic Healthcare Programs, Santa Barbara, California. This article first appeared in "Barbara's Blog" .  

Read More

Topics: Hospice Quality Measures

New Jersey Bill Would Tighten Oversight of Companion Services

Posted by Rachel Alden on Jul 7, 2014 1:22:37 PM

According to a recent article by NJ Spotlight, a bill (S-667/A-2207) recently reached Gov. Chris Christie’s desk that would expand the definition of healthcare services firms to include those that provide companion services to residents who are disabled or 60 and older. It also would require all firms to be accredited by an organization that vets Medicaid providers and to have an audit every three years. Of the more than 1,000 home care agencies in the state, more than 700 aren’t accredited. Christie hasn’t signaled publicly whether he will sign the measure.

For more on the bill and reactions from associations and advocacy groups, read the full article here



Read More

Topics: private duty home care

Nursing Home Care Too Expensive

Posted by Rachel Alden on Jul 2, 2014 11:56:32 AM

A recently released report from the National Institute of Health (NIH) and funded by the National Institute on Aging (NIA) highlights trends among America's 40 million older adults. The age group is expected to double by mid-century, growing to 83.7 million people or one-fifth of the U.S. population.

Population trends and other national data about people 65 and older are presented in the report, 65+ in the United States: 2010 . Among many other items, the report documents long-term care and housing costs and where older adults live and with whom.

According to the report, the average cost of a private room in a nursing home was $229 per day or $83,585 per year in 2010. Less than one-fifth of older people have the personal financial resources to live in a nursing home for more than three years and almost two-thirds cannot afford even one year.

“Most of the long-term care provided to older people today comes from unpaid family members and friends,” noted Richard Suzman, Director of the Division of Behavioral and Social Resarch at NIA. “Baby boomers had far fewer children than their parents. Combined with higher divorce rates and disrupted family structures, this will result in fewer family members to provide long-term care in the future. This will become more serious as people live longer with conditions such as cancer, heart disease and Alzheimer’s.”

From the National Institute of Health press release.


Read More

Topics: home care industry

CMS Releases Proposed 2015 PPS Rule

Posted by Crystal Parks on Jul 2, 2014 9:45:00 AM

On July 1, CMS issued a proposed rule to update Medicare's Home Health PPS payment rates and wage index for calendar year 2015. Payments to home health agencies are estimated to decrease by approximately 0.30% or -$58 million in 2015.The calculations don't include the 2% sequestration reduction currently in effect through March 2015 for all Medicare providers. 

This proposed rule also proposes changes to: 

  • Simplify the face-to-face encounter regulatory requirements by:
    • Eliminating the requirement that certifying physicians provide a narrative in their own words explaining why the patient is eligible for home health care. The certifying physician would still be required to certify that a face-to-face patient encounter occurred and to document the date of the encounter.
    • Limiting medical reviews to medical records from the patient's certifying physician or from the discharging facility when determining initial eligibility for the home health benefit.
    • Disallowing certification and re-certification claims by physicians when the agency claim is denied on grounds that the patient was ineligible for home health. 
    • Clarifying the face-to-face encounter requirement applies to physician's certification only, not the re-certification of eligibility for subsequent episodes. 
  • Recalibrating case-mix weights using the most current cost and utilization data.
  • Revise the home health quality reporting program requirements
    • Establish a minimum submission threshold for the number of OASIS assessments that each agency must submit. The initial compliance threshold would be 70% and will increase by 10% increments over the next two years to reach a maximum threshold of 90%.
  • Simplify the therapy reassessment timeframes by having the reassessments occur every 14 calendar days rather than before the 14th and 20th visits and once every 30 calendar days. 
  • Revise the Home Health Conditions of Participation (CoPs) for speech language pathologist personnel by replacing current stringent requirements with a more flexible option that defers to state-licensure requirements.
  • Limit the reviewability of the civil monetary penalty provisions. 
Read the propsed rule.



Read More

Topics: HHPPS

Forthcoming July First Hospice and Home Health Deadlines Fast Approaching

Posted by Lorraine Lodigiani on Jun 26, 2014 10:05:21 AM

July 1, 2014 marks the effective date and deadline date for several Centers for Medicare & Medicaid Services (CMS) polices and initiatives for both home health and hospice providers. Following is a list of those requirements along with a brief description of each.


CMS released a change request (CR) related to hospice, CR 8569 Enforcement of the 5 Day Payment Limit for Respite Care, which, effective July 1, 2014, adds language to Section 30.3 of Chapter 9 of the Medicare Benefit Manual about the use of occurrence code M2 on claims when there is more than one respite period in a billing period and instructs MACs to return to providers any claims submitted with more than 5 consecutive days billed for respite care. CR8569 does not represent a policy change but does make clear that CMS will be enforcing the 5-day limit on respite billing.


Beginning July 1, 2014, Medicare-certified hospices must directly submit a Hospice Item Set (HIS)-Admission and HIS-Discharge record for each patient admission that occurs on or after July 1. Records must be submitted electronically. In recent weeks, the Centers for Medicare & Medicaid Services (CMS) has released numerous materials to assist hospices in their preparations for the coming requirement. Failure to collect and report HIS records for July 1 through Dec. 31, 2014, will result in a 2 percent reduction in hospice payments for fiscal year (FY) FY2016. 

For recent NAHC Report coverage, please click here.


On May 2, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation: Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for Beneficiaries Enrolled in Hospice. The proposed regulation includes the following:

  • Estimates of applicable FY2015 hospice payment rates;
  • Several hospice policy changes; and
  • Requests for comment on other policy changes that CMS could consider as part of future rulemaking.

CMS will accept comments until COB on July 1.

Previous NAHC Report coverage of the proposed rule is available: herehereand here.


CMS is requiring MA plans to submit a HIPPS code for all home health claims beginning July 1. The requirement for MA plans to include a HIPPS code on home health claims had been delayed twice to allow for agencies and plans to make the necessary systems and operational  adjustments.  The MA plans are responsible for communicating this directive to their contracted providers. Agencies should be contacting the MA plans for further details and guidance.

Previous NAHC Report coverage is available hereand here


Effective July 1, 2014, HHAs are required to report the name and NPI of the physician who certifies/re-certifies the patient's eligibility (Certifying Physician). This is in addition to reporting the NPI and name of the physician who signs the patient's plan of care (Attending Physicians) when the attending physician is not the same physician who certified/re-certified the patient’s eligibility to receive services under the Medicare home health benefit.

Therefore, effective July 1, 2014, for episodes that begin on or after July 1, 2014, the certifying physician and the attending physician must be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) or have validly opted out as of the “from” date reported on the claim.

For the related transmittal and Medlearn Matters article go hereand here.


Effective July 1, 2014 CMS has the authority to impose additional alternate sanctions for home health agencies not in substantial compliance with the home health conditions of participation. Civil money penalties and suspension of payment for new admissions may be imposed, while an informal dispute resolution process will become available to agencies that wish to refute cited condition level deficiencies. Agencies have been subject to alternate sanctions that include temporary management of the HHA, directed plan of correction, and directed in-service training since July 1, 2013.

 To view CMS’ guidance on the alternate sanctions, please click here.

From the NAHC Report article 



Read More

CMS Resources Available for the New Hospice Item Set Requirements

Posted by Lorraine Lodigiani on Jun 20, 2014 11:44:33 AM

Beginning July 1, 2014, Medicare-certified hospices must directly submit a Hospice Item Set (HIS)-Admission and HIS-Discharge record for each patient admission that occurs on or after July 1.   Records must be submitted electronically.  In recent weeks, the Centers for Medicare & Medicaid Services (CMS) has released numerous materials to assist hospices in their preparations for the coming requirement. 

Failure to collect and report HIS records for July 1 through Dec. 31, 2014, will result in a 2 percent reduction in hospice payments for fiscal year (FY) FY2016. 

There are several new and updated HIS-related downloads and resources available for providers that should be reviewed in preparation for the July 1 HIS start date. Available resources and materials include:

Additional time was sought to allow for a more orderly transition resulting in more accurate data on the claim.  CMS responded with a letter dated March 28, 2014 indicating that the hospice industry has had a full eight months to prepare for the data reporting requirements and a delay is not necessary.

  • UPDATED Version of the HIS Manual (V1.01) and Relevant Change Table available on the “Hospice Item Set (HIS)” portion of the website. Providers should review V1.01 of the HIS Manual and the relevant change table to make sure they are aware of changes made from V1.00.0 to V1.01 of the HIS Manual.
  • NEW Fact Sheet about Guidelines for HIS Completion Timing is available on the “Hospice Item Set (HIS)” portion of the website. This Fact Sheet replaces previous CMS guidance about updating the HIS and provides important new information.
  • NEW Question and Answer (Q+A) Document is available on the “Hospice Item Set (HIS)” portion of the website. This document contains frequently asked HIS-related questions received on the HelpDesk January – March 2014 (the document is located in the DOWNLOADS section and labeled “April 2014 Q & A Document – FINAL”).
  • Registration for hospice User IDs – hospices will need 2 user IDs to submit HIS records to the QIES ASAP system. Information on where and how to register for these User IDs is available on the “HIS Technical Information” portion of the website.
  • Technical training modules covering HIS registration and submission processes including submission of files to QIES ASAP and using the HART software – Providers can find more information about these training modules on the “HIS Technical Information” portion of this website.

As a reminder, a recording of the HIS training, originally presented on Feb. 4 and 5, is now available at This training covers HIS data collection processes including item-specific instructions for each item in the HIS, along with tips and examples for HIS items. The HIS Training follows closely along with the HIS Manual (referenced above) and follows the HIS Training Slides. The Manual is an essential tool in understanding how to complete the HIS; it is recommended that you review the Manual prior to viewing the training.

HIS Concepts 
HART Software/Putting Records into Electronic Format

The Hospice Abstraction Reporting Tool, or HART, is a free JAVA-based application provided by CMS and made available for hospice providers to enter and validate HIS records prior to submission to the QIES ASAP system. There are four WebEx training modules available on the HART website, as well as a demonstration copy of the HART tool that is available for download and allows users to become familiar with the tool prior to going “live” July 1.

HIS Record Submission IDs

In order to submit records and receive reports on submissions, hospices must register for two IDs and passwords -- a CMSNet User ID and a QIES User ID.  Some hospices report that it has taken a few days to complete the registration process, so REGISTER NOW if you have not already done so!

CMSNet User ID 

Each provider is allowed two CMSNet User IDs which allows access to CMS’ private network where the QIES systems reside.  The CMSNet User ID registration is an online, self-registration process.  The Hospice CMSNet Online Registration application link is posted on the CMSNet Information page on the QTSO website. 

Users must follow the registration instructions contained in the Hospice CMSNet Online Registration Instructions document available on the CMSNet Information page on the QTSO website.

Following successful completion of the online registration, the user will receive two emails from the email address:

  • Email #1 – contains the user’s CMSNet user ID
  • Email #2 – contains the password associated to the CMSNet user ID, links to access the Juniper software installation document, Frequently Asked Questions (FAQ’s) and contact information

Once you have received the second email containing the password associated to the CMSNet User ID, you may begin the process of installing the Juniper communications software.  Successful installation of the Juniper software allows you to log into the CMS Network.  Should you have questions while registering for the CMSNet User ID, contact the CMSNet Help Desk by:


Once successfully logged into the CMS Network, providers will access a HOSPICE link. The Hospice link will allow users to access the CMS QIES Systems for Providers – Hospice Welcome page where the HOSPICE USER REGISTRATION application link resides. The Hospice User Registration application is used by the hospice provider to register for the QIES User IDs. The QIES User ID allows users to access the Hospice Submissions System to submit HIS records to the QIES ASAP system and to the CASPER Reporting system to access the Hospice Final Validation Report and other valuable Hospice reports.

Each provider is allowed to register for two QIES User IDs. The QIES User ID registration is an online, self-registration process. The Provider User Registration User’s Guide that details the process of registering for a QIES User ID is available in the Hospice User Registration application.

Should you have questions while registering for the QIES User ID, contact the QTSO Help Desk by phone at(877) 201-4721 or by email at

SPECIAL NOTE:  You are encouraged to review the Hospice technical training modules 1 (CMSNet User ID Registration Process) through 3 (QIES User ID Registration Process) prior to registering for the CMSNet and QIES User IDs.  The recorded training modules are available on the QTSO website.

Final Versions of the HIS Records are available on the HIS web page in the “Downloads” section.  The data specifications, which detail the requirements for the submission of HIS records, are available on the HIS Technical web page. CMS estimates that completion of the HIS-Admission will take an average of 19 minutes, while completion of the HIS-Discharge is estimated to take 10 minutes.

From the NAHC Report article June 20, 2014


Read More

Subscribe to Email Updates