May 1, 2009, Home Health & Hospice Medicare A Newsline - CGS
May 1, 2009, Home Health & Hospice Medicare A Newsline - CGS May 1, 2009, Home Health & Hospice Medicare A Newsline - CGS
BackgroundThe Medicare hospice benefit is intended to assist terminally ill patients, with a prognosis of six months orless if the disease runs its normal course, to remain in their homes. The focus of care shifts from curative topalliative care for relief of pain and symptom management. The law requires that hospice physicians certifythat the patient is terminally ill, with a life expectancy of six months or less, and periodically recertify thatthe patient continues to be terminally ill.Payment is made to a hospice for each day that an individual elects the benefit. Payment rates are adjustedto reflect local differences in area wage levels using a hospice-specific wage index, which is based onhospital wage data. Overall aggregate payments to a hospice are subject to a statutorily prescribedaggregate cap amount.The number of Medicare-certified hospices has increased significantly since 1997, up by over 70 percent.The number of Medicare beneficiaries in hospice care has also grown rapidly from just over 400,000 in1998 to close to one million in 2007.Proposed Rule DetailsThis proposed rule also solicits comments on a number of potential policy changes for the future. In orderto increase accountability in the recertification process, the rule seeks comment on requiring a physician ornurse practitioner to visit every hospice patient after 180 days on the benefit, and every benefit periodthereafter.This proposed rule also solicits comments on broader payment reform, such as alternate methods tocalculate the hospice aggregate cap.This proposed rule will be published in the April 24, 2009, Federal Register. Comments are due 60 daysafter publication by June 22, 2009. A link to the proposed rule is available at:http://www.federalregister.gov/OFRUpload/OFRData/2009-09417_PI.pdfNews from Cahaba for Home Health and Hospice ProvidersReminder of Claim Adjustments, Reopenings, and Appeal RequestsThe following serves as a reminder that will help providers in determining whether to submit a claimadjustment, a reopening request, or an appeal request.Claim AdjustmentsSubmitting adjustments are the most efficient way to add, delete or change an item or service on apreviously processed claim. However, an adjustment cannot be made to charges that were medicallydenied. Instead, you must request an appeal. An adjustment and an appeal request cannot be submitted asone request. If you wish to appeal a medically denied charge(s), your adjustment cannot be submitted untila final appeal decision is made. For information on how to adjust a claim via direct data entry (DDE), referHome Health & Hospice May 1, 2009 23Medicare A Newsline Vol. 16, No. 8
to the “Claims Corrections” section of the Fiscal Intermediary Standard System (FISS) Reference Guide,which can be viewed on our Web site at:https://www.cahabagba.com/rhhi/education/materials/fiss_correct.pdfAdjustments may be made to claims that include medically denied charges; however, the denied chargescannot be adjusted (deleted or changed). For example, an adjustment can be submitted to add physicaltherapy visits, even though the skilled nursing services are medically denied. This type of adjustment canbe submitted electronically or via DDE.Reopenings to Claims Denied Due to Unanswered Additional Development Requests (ADRs)Claims that are selected for prepayment review receive an Additional Development Request (ADR) notice.If the requested ADR documentation is not received by Cahaba within the time frame specified, the claim isautomatically denied for insufficient information. If a valid and timely appeal request is submitted with theADR documentation, within the timeframe specified for an appeal, a reopening will be done instead of anappeal. A valid request for an appeal must be received before this type of reopening is done. If a reopeningis done, and services remain denied, you still have first level appeal rights. For additional information, referto the Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, (CMS Pub.100-04), Ch. 34 §10.1 or the Medicare Learning Network (MLN) Matters article MM4147 entitled “MMA –Reopenings and Revisions of Claim Determinations and Decisions.”In addition, a claim cannot be reopened if it is already in the appeals process. A clerical error reopening isfor minor errors and omissions; however, these are usually submitted as adjustments.AppealsA redetermination (1st level of appeal) can be requested when a party is dissatisfied with an initialdetermination where items or services are not covered or ordered, because they are not reasonable andnecessary, were not intermittent, constituted custodial care, the patient was not homebound, services weredenied as not being ordered, or if the party disputes the liability of the denied or noncovered items orservices. Only the appealed items or services will be reviewed. Any changes (adding, deleting or changingitems or services) to the claim must be submitted as an adjustment request, after an appeal decision has beenmade. Services that have been medically reviewed and denied cannot be deleted from the claim. Whenrequesting an appeal, submit all medical records that apply to the items or services being appealed.The appeal request for a redetermination must be received within 120 days from the date of the initialdetermination notice (i.e., date of the remittance advice).Mail appeal requests to:Cahaba GBAMedicare A RedeterminationP.O. Box 9242Des Moines, IA 50306-9242For details about submitting ADRs, refer to the “Additional Development Request (ADR) Process”information on our Web site.Home Health & Hospice May 1, 2009 24Medicare A Newsline Vol. 16, No. 8
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BackgroundThe <strong>Medicare</strong> hospice benefit is intended to assist terminally ill patients, with a prognosis of six months orless if the disease runs its normal course, to remain in their homes. The focus of care shifts from curative topalliative care for relief of pain and symptom management. The law requires that hospice physicians certifythat the patient is terminally ill, with a life expectancy of six months or less, and periodically recertify thatthe patient continues to be terminally ill.Payment is made to a hospice for each day that an individual elects the benefit. Payment rates are adjustedto reflect local differences in area wage levels using a hospice-specific wage index, which is based onhospital wage data. Overall aggregate payments to a hospice are subject to a statutorily prescribedaggregate cap amount.The number of <strong>Medicare</strong>-certified hospices has increased significantly since 1997, up by over 70 percent.The number of <strong>Medicare</strong> beneficiaries in hospice care has also grown rapidly from just over 400,000 in1998 to close to one million in 2007.Proposed Rule DetailsThis proposed rule also solicits comments on a number of potential policy changes for the future. In orderto increase accountability in the recertification process, the rule seeks comment on requiring a physician ornurse practitioner to visit every hospice patient after 180 days on the benefit, and every benefit periodthereafter.This proposed rule also solicits comments on broader payment reform, such as alternate methods tocalculate the hospice aggregate cap.This proposed rule will be published in the April 24, <strong>2009</strong>, Federal Register. Comments are due 60 daysafter publication by June 22, <strong>2009</strong>. A link to the proposed rule is available at:http://www.federalregister.gov/OFRUpload/OFRData/<strong>2009</strong>-09417_PI.pdfNews from Cahaba for <strong>Home</strong> <strong>Health</strong> and <strong>Hospice</strong> ProvidersReminder of Claim Adjustments, Reopenings, and Appeal RequestsThe following serves as a reminder that will help providers in determining whether to submit a claimadjustment, a reopening request, or an appeal request.Claim AdjustmentsSubmitting adjustments are the most efficient way to add, delete or change an item or service on apreviously processed claim. However, an adjustment cannot be made to charges that were medicallydenied. Instead, you must request an appeal. An adjustment and an appeal request cannot be submitted asone request. If you wish to appeal a medically denied charge(s), your adjustment cannot be submitted untila final appeal decision is made. For information on how to adjust a claim via direct data entry (DDE), refer<strong>Home</strong> <strong>Health</strong> & <strong>Hospice</strong> <strong>May</strong> 1, <strong>2009</strong> 23<strong>Medicare</strong> A <strong>Newsline</strong> Vol. 16, No. 8
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