Processing Time For Medicare Appeals Expected To Go Up

Judge Nancy J. Griswold, Chief Administrative Law Judge (ALJ) and Director of the Office of Medicare Hearings and Appeals (OMHA), recently met with the National Hospice and Palliative Care Organization (NHPCO) staff. The workload for the ALJ was discussed in depth, as well as the backlog and any considerations for a faster response to appeals. Judge Griswold reported that the average processing time for fiscal year 2015 is 547.1 days and is expected to go up.

There is a new resource for appellants who want to check on the status of an email. Go to the OMHA website and click on “Appeal Status Lookup.” Judge Griswold also commented that the settlement from CMS for hospitals could remove up to 280,000 appeals from the ALJ backlog, but is not expected to completely fix the issue. Providers can also register for the OMHA listserve to get information on the ALJ appeals.


CMS Releases Change Request Outlining Penalties For Hospice Agencies That Do Not Submit Required Quality Data

CMS has issued change request (CR) 9091, which addresses payment to hospice agencies that do not submit required quality data and outlines the penalties for failure to report. For fiscal year 2014, and each subsequent year, if a hospice agency does not submit required quality data, their payment rates for the year will be reduced by 2% for that fiscal year. The 2% reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year. Additionally, reporting-based reductions to the market basket increase factor will not be cumulative and will only apply for the fiscal year involved.

“For calendar year 2014, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after July 1, 2014, through December 31, 2014, as meeting the reporting requirements. For calendar year 2015 and subsequent years, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after January 1 through December 31 as meeting the reporting requirements for that year. Hospices that receive notification of Medicare certification on or after November 1 of the preceding year involved are excluded from any payment penalty for quality reporting purposes for the following fiscal year.” 

Click here to see CR 9091.

Click here for more information from NAHC.

NAHC Adds ICD-10 Resource Page To Its Website

NAHC has added an ICD-10 Resource Page to its website to help home care and hospice agencies transition to the new coding system, and to provide up-to-date information on the ICD-10 update. NAHC and the home health and hospice vendor community have a shared goal in assuring that agencies are adequately preparing for the transition from ICD-9 to ICD-10 diagnosis coding. The page includes education and guidance materials along with tools to assist NAHC’s members in attaining that goal.

Click here to see it.

Tiptastic Tuesday: 5 Ways To Improve The Palliative-Care Patient Experience

According to new research published in the Journal of Pain and Symptom Management, palliative care providers can significantly reduce their patients’ risk of unnecessary physical and emotional discomfort if they meet 10 quality measures. The research is the result of a two-year project that began with a list of 75 quality indicators which the research team reduced to 10.

Of the 10 recommendations, five include:

  1. Hospice and palliative care patients should receive comprehensive physical, social, spiritual, functional, and psychological assessments soon after admission.
  2. Seriously ill patients should be screened for symptoms, including pain, nausea, and shortness of breath as part of their admission visits.
  3. Patients whose illnesses are advanced or life-threatening and whose screening indicate shortness of breath should develop a plan for managing it.
  4. Seriously ill patients should document their life preferences regarding life-sustaining care.
  5. Providers should give hospice/palliative care patients or their families a relevant survey to assess their care experience.

Click here to read more.

2015 OIG Work Plan Highlights: Hospice Services

Yesterday, we highlighted the home health services section of the 2015 OIG Work Plan. Today, we’ll take a closer look at the hospice services section of the Work Plan:

For beneficiaries living in assisted living facilities, the OIG will review the level of services provided, including the length of stay, level of care received and common terminal illnesses. This information is necessary for CMS to reform the hospice payment system, collect data relevant to revising hospice payments, and develop quality measures. Furthermore, hospice care may be provided to individuals and their families in various settings. These settings include the beneficiary’s place of resident, such as an assisted living facility. Typically, assisted living facility residents have the longest lengths of stay in hospice care, thus requiring more monitoring and examination.

The OIG will also assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. The OIG will review hospice medical records to address concerns that this level of hospice care is being misused. Beneficiaries may revoke their election of hospice care and return to standard Medicare coverage at any time.

Click here to see the plan.

OMHA Seeks Input On Ways To Reduce Medicare Appeal Backlog

The Office of Medicare Hearings and Appeals (OMHA) has recently published a “Request for Information” regarding the Administrative Law Judge (ALJ) Program for Medicare Claim Appeals. The Request follows a OMHA Appellant Forum where OMHA officials “detailed the ever-increasing appeal backlog along with its initiatives to bring greater efficiencies and productivities into the ALJ appeal process.”

There are nearly 900,000 ALJ level appeals awaiting assignment and processing. Due to the volume of pending appeals, the assignment of appeals to ALJs has been suspended since July 2013. OMHA has has taken steps to improve the appeals process since the backlogged appeals began. NAHC has recommended that CMS “institute a mass settlement option that offers the home health and hospice community a quick and simple process for a compromise settlement based on historical ALJ reversal rates.”

Click here to access the Request for Information.

Click here to read more from NAHC.

OIG 2015 Work Plan Released

The Office of the Inspector General (OIG) has just released its 2015 Work Plan and it looks a lot like its 2014 plan. The OIG will still be focused on inappropriate Part A and Part B billing in Nursing Facilities; general inpatient care billing for Hospice; compliance with PPS requirements in home health, with special scrutiny on newly enrolled home health agencies as well as review of employment of individuals with criminal convictions in the home care setting. The OIG will also still be looking at inappropriate Part B billing for Chiropractor services; place of service coding errors for Physician services; and the high use of outpatient Physical Therapy services.

To read the OIG’s full plan, click here.