Hospice Associations Send CMS Proposed New Guidelines for Hospice Medical Review As reported in 2001, the Hospice Association of America (HAA), American Academy of Hospice and Palliative Medicine (AAHPM) and the National Hospice and Palliative Care Organization (NHPCO) met with the Centers for Medicare and Medicaid Services (CMS) last April to discuss how the medical review process might be improved. CMS had indicated interest in trying to increase access to the Medicare hospice benefit by offering a prior authorization process that was not embraced by the industry. CMS later related that if prior authorization was not the answer, they would be interested in discussing other ideas and working with the hospice industry to come up with a solution. CMS stated that they do medical review on a small percentage of hospice claims so there is not a lot of money available, however they wanted to work with hospice industry representatives to develop a system that will make the best use of these dollars. The objective was to improve access to hospice services, with referrals on a more timely basis, for all who are eligible and choose to use these services. Since that time, HAA has sought input from hospice members and met with the other national hospice associations to develop a proposal to share with CMS which could be supported by all three of the associations. After a great deal of discussion and consideration, the three associations have agreed on the following proposal and it has been sent to CMS for its contemplation. The associations will be meeting with CMS on January 22 to discuss this joint proposal. HAA will keep members informed on next developments. Proposed Medical Review Guidelines Developed and submitted to The Centers for Medicare and Medicaid Services by the Hospice Association of America, the National Hospice and Palliative Care Organization, and the American Academy of Hospice and Palliative Medicine. The physician’s clinical judgment is determinative of prognosis for a hospice patient certified for the Medicare Hospice Benefit, unless there is evidence to support a suspicion of abuse. Where fraud and abuse is alleged, the burden of proof lies with the fiscal intermediary. Rationale: The Benefits Improvement Protection Act (BIPA) of 2000 amended Section 1814 (a)(7) of the Social Security Act, 42 U.S.C., by adding the following language: " The certification regarding terminal illness of an individual shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness." Program Integrity Manual, Chapter I, 3.1 Examples of Medicare Fraud Consider reviewing hospice claims for prognostic eligibility only for hospice programs with lengths of stay or live discharges above established thresholds for a full year. The threshold calculations represent each hospice’s program as a whole for all patients served irrespective of diagnosis. The threshold for a hospice’s one-year population would be: Length of stay: Discharges Alive: Patients over 6 months > 20% Live discharges >20% All patients served All discharges, dead and living Limit subsequent reviews of programs that have exceeded the 20% threshold but were found to be operating appropriately following review by requiring the FI to show evidence to support a suspicion of abuse above and beyond the threshold data. Note that under certain situations a hospice program could exceed the 20% LOS threshold without triggering medical review. These situations might include, but are not limited to, the following: Early identifiers. Certain hospice programs have a proven track record in early identification of eligible patients when compared to other hospice programs. In these instances, hospice programs are highly successful in identifying eligible patients early in their disease trajectory and thus could have a higher LOS threshold than other programs. Well-integrated programs. Certain hospice programs have been highly successful in communication and integration with other facets of the relevant community, such as other health providers and systems, the aging network, end of life institutions and other appropriate community entities. These hospices could exceed LOS thresholds based solely on their ability to attract eligible patients through their success in community networking and education. Other situations. Such other situations as the Secretary deems appropriate. For hospice programs who exceed the threshold for live discharges, include a narrow exception process for hospice programs outside peer norms for reasons such as: unique patient mix, geographic disparities, seasonal population, etc. The exception process should be based on the extraordinary circumstances category described above. For example, hospice programs in a resort setting tend to have higher discharge rates as their patients enroll while temporarily in the area. (Hospice regulations allow for one transfer per benefit period, however, the patient must still be discharged after leaving a temporary hospice, even visited briefly because it was located in a resort setting.) These discharge cycles can significantly increase the discharge rate. Include an administrative process to allow CMS to increase the 20% threshold based on changes in statute, regulation, demographics, etc. While we are proposing a new threshold as a tool to efficiently administer the Medicare program, it is important to note that the hospice benefit is by statutory and administrative design not time limited. Former HCFA Administrator Nancy-Ann Minn Deparle in a September 12, 2000 letter to hospice programs noted that eligible patients should receive prompt care regardless of the difficulty in determining prognosis. According to the former Administrator, "In no way are hospice beneficiaries restricted to six months of coverage. There is no limit on how long an individual beneficiary can receive hospice services, as long as they meet the eligibility criteria." Rationale: Program Integrity Manual, Chapter 2 – Identifying and Developing Aberrancies and Leads – 2.4.3.1 E evidence of over utilization CAHABA GBA - Midwest, Prostate LMRP, " Normal course" for the purpose of this policy means in general no more than 20% of patients survive over 6 months. Providers who consistently show evidence that greater than 20% of patients survive over 6 months may be subject to further review. A provider who exceeds the 20 % threshold could be subject to a "probe" review to validate potential problems. "Before deploying significant medical review resources to examine claims identified as potential problems from data analysis, take the interim step of selecting a small "probe" sample of potential problem claims (prepayment or postpayment) to validate the hypothesis that such claims are being billed in error. This ensures that medical review activities are targeted at identified problem areas." HCFA Program Memorandum – Transmittal AB-00-72 dated August 7, 2000. Subject: Medical Review Progressive Action (PCA) - Action When reviewing for prognostic eligibility under the parameters set above, FI medical review staff should: Use only the information available to the certifying physicians, representing the documentation and clinical course of the patient prior to certification or re-certification. Example: Medical Review of a chart for eligibility during May 2001, with a date of certification, May 5, 2001. The information that should be reviewed would be documentation from months prior to May 5 (i.e. February, March, April), which the physician used to (re) certify the patient on May 5. Documentation for care provided after May 5 should not be considered relevant to the patient's eligibility determination for the benefit period under review. Rationale: HCFA ruling HCFAR 93-1 May 18, 1993 states, "In determining whether the health care services provided were reasonable and necessary, the medical review entity confines its review to the medical record associated with the inpatient stay, which is a discrete past event. "No judgment of the probable future course of the patient….is expected." "The only questions that can be considered based on the evidence in the medical record are the reasonable and necessary of the patient’s admission to the institution and his or her continued stay. Both are discrete past events that can only be reviewed from a documentary medical record. Although the physician must make prospective judgments about the need for initial and continuing inpatient care, the medical review entity has the benefit of hindsight in reviewing a case retrospectively. For this reason, the review criteria set forth in regulation, Rulings, and other pertinent guidelines recognize that a physician’s opinion and medical judgment should be evaluated in terms of the information available to the physician at the time. Assume the certification valid for the entire benefit period. Rationale: The Medicare statute provides coverage of hospice services during specified benefit periods, and requires that beneficiaries be certified or re-certified as being terminally ill (as defined in the statue) at the beginning of each benefit period. Eligibility is then presumed until re-certification is required at the start of the next benefit period. While hospices continue to monitor and document patients' medical condition throughout the time they receive hospice care, hospices should not be required to reassess the prognosis of a patient continually throughout each benefit period. Terminally ill patients' conditions do improve and decline intermittently as part of the natural course of their illness, but hospices should not be held to a standard that would require them to repeatedly discharge and readmit these patients to the hospice. This would be emotionally traumatic for patients and detrimental to patient care.. Once a patient is certified at the beginning of a benefit period, eligibility for hospice care during that period should not be re-visited by FI medical review staff during that period except in the rare case of a clear and dramatic improvement in the patient's condition that is expected to be maintained significantly beyond the hospice benefit period, and the burden of justifying such an interim reevaluation should be on the FI. Recognize that documentation to support the prognosis is not limited to information referenced in an LMRP. LMRPs are but one tool to assist a provider in documenting the rationale behind a physician’s clinical judgment related to prognosis. Any other supporting documentation can and should be included with an LMRP, or used in place of an LMRP. "Medical Necessity" for Hospice is necessarily entailed by a physician certified terminal prognosis of 6-months or less if the disease runs its normal course. The terminal prognosis inherently creates a crisis with resulting need for physical, emotional, social or spiritual intervention by an interdisciplinary hospice team. If a patient dies within six months of the initial certification, assume without medical review that the patient was terminally ill and thereby eligible to elect his/her benefit.