7/26/2016
Hospice Revenue Cycle: Protecting Cash Flow Through Revenue Cycle Processes •
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Dawn Michelizzi ‐ Senior Vice President for Finance & CFO of VNA of Greater Philadelphia
Anthony Smith ‐ Associate, BlackTree Healthcare Consulting 1
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Identify potential risks that may cause a decrease in hospice reimbursement
Gain a better understanding of items that may hold bills from being submitted
Review EMR updates
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2016 Hospice Statistics:
 Census: 230
 Average length of stay: 50 days
Two divisions
 Days outstanding growing
 Checks and balances
 Paperless/scanning
 Stuck in the past/turnover
 Front end/back end
 Change with growth
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 Four teams
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 Management oversight of all business related functions of the completed patient documentation to accurate adjudication of the patients account
 Oversees Intake, Orders Tracking, Medical Records and Billing
 Monitors aged accounts and verifies appropriate collections procedures are being followed
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 Increase intake staff to assist in the collection of information during the referral process
 Use a document management software to tracking outstanding orders
 Develop a process to ensure all NOEs are entered timely
 Address denials on a daily basis
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Stress the importance of gathering as much clinical documentation at the referral
 Medications
 CTI
Educate the department on the Medicare Common Working File (CWF) to identify potential overlaps with other agencies
 Equipped all staff with dual screens
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 Reduces errors
 Reduces toggling between screens
 Reduce costs
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 Note of Election (NOE) filed
 Valid Certification of Terminal Illness
 Face‐to‐face (for 3rd benefit period)
 Coverage criteria met
 All system edits cleared
 New NOE processing changes coming soon
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 The hospice agency must file the Notice of Election (NOE) with its Medicare Administrative Contractor (MAC) within the first 5 days of admitting the patient
Reimbursement will be reduced for NOEs not submitted in the time frame
 The NOE must be finalized in the MAC’s claims processing system (FISS) before the hospice agency can submit its first claim
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Used when the receipt date on your notice of election (NOE) is more than 5 days after the admit date, your NOE is considered untimely
 Acceptable exception examples
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 A hospice required to remove a timely filed NOE to allow a prior hospice to bill.
 A timely filed NOE that was returned (RTPd) due to an open prior hospice benefit period.
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Correct use of the NOE late exception modifier (KX) for NOEs.  Ensure the modifiers are removed on the correct date
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 Intermediary specific:
CGS and NGS makes you ADR and send medical records in on all claims
Palmetto allows comments in remarks section for some reasons and they will process  Ex‐provider # being activated for a new agency and we are back billing the claims . Billing NOE late due to other agency billing
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 The Certification of terminal Illness (CTI) applies to each benefit period
 The patient must be certified he/she has a life expectancy of six months or less
 For the first 90 day benefit period, the hospital medical director (or the physician who is a member of the interdisciplinary team) and the patient’s attending physician, id applicable, must certify the patient
Nurse practitioners are not allowed to certify the patient’s life expectancy
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The hospice must obtain verbal or written certification of the terminal illness, no later than 2 calendar days (by the end of the third day) after the start of each benefit period (initial and subsequent).
 Initial certifications may be completed up to 15 days before hospice care is elected.
 Recertifications may be completed up to 15 days before the start of the next benefit period.
The hospice agency cannot submit any claims until the certification/recertification is signed and dated by the physician(s)
If the certification/recertification is not done timely, the days of care that are not covered are reported on the claim under occurrence code 77
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 For all subsequent benefit periods, only the hospice medical director (or the physician who is a member of the interdisciplinary team) must certify the patient
 The CTI must include a narrative from the physician
The narrative must support the life expectancy of six months or less, and it must include an attestation statement
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F2F encounter is required for:
 Any patient entering his/her 3rd benefit period
 F2F encounter must be conducted by:
 A physician employed/contracted by or a volunteer of the hospice agency
 A nurse practitioner employed by the hospice agency
 The F2F encounter must be conducted no more than 30 days prior to the start of the 3rd benefit period and every benefit period thereafter
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 If the F2F is not done timely:
The hospice must discharge the patient
Continue to provider care to the patient at its own expense, until the F2F encounter is completed appropriately and the hospice is able to readmit the patient
The patient must also complete a new election statement
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 Tracks outstanding orders
 VNA three sources
 Reduces order turnaround time  Allows team members to easily collaborate
 Allows agencies to go paperless
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 Pre Billing:
Include technical and clinical reviews
 100% review of the NOE, CTI and F2F
 Medications review
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Admission criteria‐does patient meet criteria for terminal illness
 Documentation supports level of care provided
 Content of CTI supports terminal condition and documentation supports were obtained timely
 Pharmacy Charges entered into the EMR
 Patients receiving services in nursing homes
 Patients in GIP facilities
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 Beginning January 2016, new payment structure for hospice routine care:
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Days 1‐60
Days 61+
Last 7 days of life: Additional payment for registered nurse and social worker visits (Excludes LPNs)
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SIA payments are in addition to the per diem Routine Home Care Rate (RHC) when all the following criteria are met:
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The day is a RHC level of care day
The day occurs during the last 7 days of the patient’s life, and the patient is discharged expired
Direct patient care is provided by a registered nurse (RN) or social worker that day
The SIA payment will equal the Continuous Home Care (CHC) hourly payment rate, for a minimum of 15 minutes and up to 4 hours total per day
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 Recommended to review accounts that qualify for the SIA payment for the following:
Is the EMR calculating the correct SIA amount
 Is Medicare reimbursing at the correct SIA amount
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 New HCPC Codes as of 1/1/16
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G0299 (RN services)
G0300 (LPN services)
 Retired code as of 1/1/16
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G0154
 Applies to both hospice & home health
 NPI’s must be configured for SNF claims
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Billing
 Sequential Billing
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Previous months claims need to be “processed” prior to current month being billed
Paid, Rejected, and Denied claims are considered processed
Suspended (S‐status) and RTP (T‐status) are not considered processed
 Monthly Billing
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Billing should be performed on a calendar month basis
Should not have multiple months on one claim
Services paid for on a per diem basis
 Per diem rates are dependent on the patient’s level of care
 Multiple level of cares can occur during the month
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Claim clearinghouse  Rejections and errors should be worked daily to ensure all claims are addressed
 Timely follow up of denials in the FISS system
 Daily follow‐up of RTPs, rejections, and denials  Medicare manual reviews
 Monitor and contact Medicare if claims are in a manual review status for 30+ days
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 Authorization
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 Overlaps need to be addressed as they are discovered
 Important to reach out to overlapping provider to confirm their discharge date
 Unpaid claims will impact the NOE submission for your agency
 NOTRs/Transfers
Review CWF for discharge date
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8XB must be filed by other agency
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 Accuracy and timeliness of the DOD
 Reduce denials
 Allows bills to be release before the end of the month 30
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 Utilized aging reports to protect against timely filing denials
 Missing documentation report
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 Abide by the CMS NOE guidelines
 Ensure hospice medications are entered in software system in a timely manner
 Gather as much clinical documentation during the intake process  Address claim denials as discovered
 Confirm that the EMR tables are current with hospice regulations
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 Anthony Smith, BlackTree Healthcare Consulting
 [email protected]
 Dawn Michelizzi, VNA of Greater Philadelphia
 [email protected]
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