STATE HOSPICE ORGANIZATION AND PALMETTO GBA …



STATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION

MEETING SUMMARY

For meeting held on November 17th, 2010

Columbia, SC

Included in this report:

NCLOS report

ZPICs and other Audit activity

Updated CAP report

Update on the MAC Award

Palmetto Discussion points

Advanced Beneficiary Notices

New ICF blog

What is the best interpretation of the Alzheimer's LCD?

The following is a summary of the information gathered at the meeting. It includes data from the conversations, dialogue and discussion as well as information provided in any handouts. No information provided in this summary is intended for legal or operational advice but merely as information for planning and awareness. This summary is provided as a service to members of Florida Hospices and Palliative Care. Please be aware that the statements have not been evaluated or approved by Palmetto GBA or the other members of the coalition. Questions submitted to Palmetto GBA by hospice coalition members with the responses provided will be published separately when they are made available electronically from Palmetto GBA.

NCLOS audits – update on status

➢ Most recent NCLOS rates are available on the website $FIle/NCLOS_Rate_Slides_by_State_2half2009.pdf

➢ No new discussion regarding NCLOS rates

➢ When most recent letters were sent, 128 were returned to Palmetto. Palmetto reminds providers that changes in addresses, ownership and other information must be processed with correct 855A forms and submitted to Palmetto in a timely fashion.

➢ Mail sent from Palmetto will not be forwarded by the post office.

Various other audit types

Zone Program Integrity Contractors (ZPIC) activity – there are varying degrees of activity around the country. In Georgia, there are several ZPIC audits in different stages of completion, no common factors identified. Florida, Texas, California, Arizona and Illinois remain “hot spot” areas per CMS with no specific focus on hospice. ZPICs audit providers across the continuum of fee-for-service activity and pull data from a variety of resources to provide snapshots of service overlap and potential areas of abuse.

Florida is in Zone 7, along with Puerto Rico and the U.S. Virgin Islands. The ZPIC contractor for Zone 7 is SafeGuard Services, LLC (a HP Company).

If your program is contacted by the ZPIC for audit, please let me (Paul Ledford) know so that we can monitor activities in Florida.

To learn more about the ZPIC program, it’s background and how it can affect you, please visit this link: (RHHI)~Articles~General~8AFPJY5478?open&navmenu=%7C%7C

RAC contracts – CMS has mandated that RAC contracts be in place within the region by 12/31/10 and implementation of integrity audits by 4/1/11

Palmetto audits 2010

Focus for Palmetto review program is currently aimed at providers who meet the following three conditions:

➢ Exceeded the hospice CAP

➢ Exceeded the NCLOS rate for all providers

➢ Exceeded the ALOS for all beneficiaries (regardless of diagnosis)

Palmetto reminds providers that with the transition to new systems and integrity programs via RACs and ZPICs, audit activities will be subject to change. Medical review requests will remain in place.

CAP discussion

Current 2009 CAP report as of 11/17/10. There are still 9 states with 0% review completed as of this date. Thirteen states have 100% completed reviews. Thus, the remaining 28 states are in varying degrees of completion as of this report. The following table represents those 16 states within the Palmetto RHHI jurisdiction.

|State |Total Providers |Total completed |% completed with Overpayment |Total CAP overpay amt |

|Alabama |113 |113 |45% |$26,983,118 |

|Arkansas |30 |30 |3% |$89,368 |

|Florida |37 |35 |9% |$1,874,843 |

|Georgia |108 |106 |25% |$7,432,488 |

|Illinois |60 |59 |12% |$627,145 |

|Indiana |57 |56 |11% |$1,847,199 |

|Kentucky |15 |15 |0% |---- |

|Louisiana |124 |108 |22% |$5,700,476 |

|Mississippi |104 |102 |55% |$34,017,464 |

|North Carolina |63 |52 |6% |$627,041 |

|New Mexico |29 |23 |26% |$4,377,271 |

|Ohio |77 |39 |0% |---- |

|Oklahoma |116 |36 |17% |$3,066,275 |

|South Carolina |1 |0 |0% |---- |

|Tennessee |47 |0 |0% |---- |

|Texas |266 |0 |0% |---- |

MAC Update

Palmetto was finally awarded the RHHI jurisdiction 11 with MAC region C on 9/9/10. This will have a minimal impact on current hospice and home health providers under the RHHI but could impact those providers with multiple locations across states that are not served under the new MAC award. However, this is not anticipated for some time as there are still MAC awards up in the air and no transitions will be finalized until the awards are completed. The impact on those providers designated as hospital-based which may be served under a different MAC now is not yet known by Palmetto but is under review.

What providers should expect:

➢ Communication from Palmetto regarding implementation of new processes, systems, etc that may impact operations

➢ Changes will include updated contact information for the Provider Contact Center, new payer ID’s for electronic claims and a new website address: HHH which will be the locus for all things related to the MAC transition

➢ Things that will NOT change include:

o LCDs – these are already in place and will remain

o Provider Outreach and Education (POE)

o EFT agreements

o Palmetto GBA departmental addresses and telephone numbers

o Claims processing systems (FISS)

➢ An Implementation Guide for Home Health and Hospice will be released soon

Please note that home health and hospice providers are already served by Palmetto via the RHHI Jurisdiction 11 and what is actually changing is the designation for Palmetto GBA to an official Medicare Administrative Contractor or MAC for this Jurisdiction.

Palmetto Points

➢ Palmetto provided information about the Online Provider Services (OPS) system that is designed to meet the needs of providers in real-time online format with ease of navigation and access to information that was previously conveyed via fax or mail. The OPS application will allow providers to check eligibility, claims status, remittances and look at financial information pertinent to the provider’s status. Providers with current EDI enrollment agreements on file with Palmetto can participate now. Providers who do not yet have EDI on file must visit and follow the links to access EDI enrollment information.

o Palmetto expanded further on this system in light of the new requirements for Face to Face visits. The need to determine benefit period and Medicare status at the time of a referral, admission or transfer is imperative for providers to ensure correct dates, assessment periods, etc. The OPS pulls data from the HIPAA Eligibility Transaction System (HETS) and DDE so provides the most current, flexible, accessible and navigable data available to providers. DDE system is only available at certain times while the OPS will be accessible 24/7 and anyone at the hospice agency can retrieve information from the system.

o Use this link to learn more about the OPS: (RHHI)~Online%20Provider%20Services~Access%20OPS?open&expand=1&navmenu=Online^Provider^Services

➢ ANSI 5010 Transition is almost here! Are you ready??

o Implementation activities are underway by CMS to convert from ASC X12 4010A1 to ASC X12 5010. January 1, 2011 will mark the start of submission for new claims with 5010 designation and December 31, 2011 will be the last day to submit the 4010 claims.

o Transitioning to the 5010 platform provides enhanced support of E-Health systems, claim numbers are assigned on the front end and returns claims in need of correction to providers earlier in the process. The platform is also a pre-requisite for the new ICD-10 code values.

o What should providers do to be sure they are ready to handle this transition?

▪ Contact your software vendor and ask what they are doing to prepare for the upgrade. The response should provide you with guidance for next steps.

▪ Utilize resources on Palmetto and CMS websites to learn about new reports and data entry requirements for claims processing

▪ Visit this link for current information related to the 5010 transition:

➢ There was quite a bit of discussion regarding the requirement for a physician’s signature for a verbal certification. It has long been understood that a signature from the physician who provided the verbal certification was a Palmetto-specific mandate, though not found in statute. At this meeting, Palmetto Medical Review clarified that there must be documentation that a verbal certification was obtained if it is necessary to ensure timely certification of the patient’s eligibility but the signature of the physician was not the only acceptable method to document this. Medical Review did state that this method was preferable and providers at the table commented that having the physician’s signature to authenticate the verbal certification was helpful during audits. However, it is not required. Providers are reminded that the Palmetto training manuals are obsolete and current references are found in the Internet-Only Manuals (IOM) at manuals Palmetto did remind providers to check with state regulations to determine if there was a requirement at that regulatory level.

Advanced Beneficiary Notices

➢ Palmetto provided guidance regarding the use of the ABN for care or treatments provided outside the hospice plan of care, including hospitalization. The primary discussion was whether or not this form can be used after such care is discovered (examples were provided). Palmetto stated that the ABN, by definition, is to provide guidance to the beneficiary before such care or treatment is received and cannot be given to the beneficiary after the fact. Hospice providers must have a clear process for educating beneficiaries and their representatives at the time of admission regarding those services or treatment options which exist outside the plan of care and who the contracted providers are. The provider is encouraged to ensure a process exists to provide counseling and guidance to beneficiaries and their representatives regarding the options available at the time it is discovered that care or treatments have been provided.

Update from Dr. Feliciano on LCDs, ICF system and “Going Beyond Diagnosis”

Dr. Feliciano provided a special report from the IAC to introduce a new resource for the Going Beyond Diagnosis (GBD) dialogue. He has established a blog to provide an online space for sharing information to enable use of the ICF going forward. There is a case scenario on Parkinson’s developed by the IAC on the blog and can be found at:

goingbeyonddiagnosisblog

Dr. Feliciano emphasized the use of the ICF to inform a greater perspective of eligibility that looks at a patient’s body structures and functions, activities and levels of participation and environmental factors as important elements in determining morbidity. He reminded us that use of the ICF will help to communicate the patient’s needs, focus interventions, track related outcomes and inform payment decisions in the future. Currently, only Palmetto is implementing this structure in eligibility commentary but he feels strongly that other services will incorporate this philosophy as demonstrated correlations are identified between LOS, eligibility determinations and patient-centered care.

To review all materials on the Palmetto GBA website related to Going Beyond Diagnosis, please visit:

(RHHI)~Learning%20Education~Going%20Beyond%20Diagnosis%20Series

Coalition Questions and Answers – a complete list of the questions submitted to Palmetto by coalition members will be published by Palmetto when the edits are finalized. The summary below is only preliminary.

Q: What is the best and most correct way to interpret the LCD for Alzheimer’s, especially the FAST?

The Palmetto GBA LCD regarding Alzheimer’s Disease states that “to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions meeting the above criteria.” This refers to the Alzheimer’s Disease “Stage 7”:

Stage 7: Loss of speech, locomotion and consciousness:

- Sub-stage 7a: Ability to speak limited (1 to 5 words a day)

- Sub-stage 7b: All intelligible vocabulary lost

- Sub-stage 7c: Non-ambulatory

- Sub-stage 7d: Unable to sit up independently

- Sub-stage 7e: Unable to smile

- Sub-stage 7f: Unable to hold head up

In 2004 Palmetto GBA revised its LCD addressing Alzheimer’s disease in recognition of the complex decision-making involved in making hospice referrals for this heterogeneous population. The goal was to make the LCD more descriptive, rather than prescriptive. The FAST threshold was revised from Stage 7C to Stage 7 PLUS relevant secondary and/or comorbid conditions, therefore, if an individual has lost speech, locomotion or consciousness as a result of the Alzheimer’s disease, they would meet the FAST criterion.

Because the FAST scale was designed to measure only the functional impact of the Alzheimer’s disease itself, Palmetto GBA incorporated the concepts of secondary and/or comorbid conditions in the revision. Both the FAST and the secondary/comorbid condition criteria are important in painting the picture for individuals with Alzheimer’s disease at the end of life.

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