The hospice eligibility conundrum
The resumption of the Hospice TPE as brought with it a rash of new technical denials, including denials related predominantly related to the new Notice of Election and Election of Benefit form requirements. Many hospices are finding themselves on the denial end of the TPE process as the MAC reviewers are denying claims on the technical basis that the election of benefit form did not contain all the required elements.
The 2020 Hospice Final Rule, as published on August 6, 2019, in the Federal Register (84 FR 38484), not only updated the FWI, but also modified the election statement and required a new addendum designed to “increase coverage transparency for patient under a hospice election” (FY 2020 Hospice Wage Index…Requirements, 2019). In the middle of an unprecedented public health emergency, many hospices were more focused on managing PPE shortages, staffing crises and acutely ill patients in a complicated care environment than on ensuring that they implemented a new and correct form and process. The result? Many smaller hospices were blindsided by the literal interpretation of the new EOB requirements.
What Were These Denials?
The most commonly seen technical denials have been related to a very literal interpretation of the rule that is requiring the presence of exact wording from the Final Rule document. For many, there was a sense that they could interpret the requirement and use a less that literal approach to their revised NOE/EOBs. One example of the verbiage being cited is around what appears to be magical words “exceptional, unusual and rare” in regard to services unrelated to the terminal illness. Another common reason for claim denial is that the Notice of Election does not include acknowledgement that individual, or representative be “given a full understanding of the palliative rather than curative nature of hospice care.”
The Outcome?
While many of these denials are only just making it to the level of appeal, the trend is not promising for those hospices who failed to use the exact verbiage as found in the Hospice Election Statement Example that was shared by CMS.
What Next?
As hospices get back on their feet as this pandemic slows down, compliance teams need to take a close look at the required Election of Benefit forms to ensure that all the required elements are included. Review your process for the new Addendum and ensure that your agency is compliant with the changes that were written into law. In addition, always make sure that you are keeping abreast of any and all regulatory changes. If you aren’t sure whether you have achieved compliance, don’t risk going it alone. Engaging a professional support consultant with a high level of expertise can help steer your hospice away from compliance risk.
FY 2020 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirement, 42 CFR § 418 (2019).
Putting the PI back in QAPI
