Palmetto GBA has released the findings of its latest Targeted Probe and Educate (TPE) review of hospice routine home care.
The review included 40 claims, with 37 denied. The results include important reminders about compliance around the Notice of Election and the Plan of Care.
Palmetto shared the following on NOE compliance:
A Medicare beneficiary must complete an election statement before the hospice Medicare benefit can begin. The election statement must include the following items of information:
- Identification of the particular hospice that will provide care to the individual
- The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
- The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
- The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.
- The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or nurse practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, National Provider Identifier (NPI). number, or any other detailed information to clearly identify the attending physician.
- The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice
- For hospice elections beginning on or after October 1, 2020, the hospice must provide:
- Information on individual cost-sharing for hospice services
- Notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice
- Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information
- The signature of the individual or representative
Palmetto also noted how to avoid denials around the Plan of Care:
- The hospice must submit a plan of care for dates of service billed when responding to the Additional Documentation Request (ADR)
- All dates billed must be covered by a plan of care to be payable under the Medicare hospice benefit
- If more than one plan of care covers the dates of service in question, submit all the related plans of care for review
- The plan of care must contain certain information to be considered valid. This includes:
- Scope and frequency of services to meet the beneficiary’s/family’s needs
- Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
- Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions
- The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment
- All hospice care and services must follow an individualized written plan of care
- The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.