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View this email online! Hospice Notes, 6/28/2016 View Previous Issues!




NAHC recently received word that in addition to the Hospital & Healthcare Compensation Service national studies, the organization is conducting a pilot study for Oklahoma hospices that is complimentary to participants.  H & HCS is testing new jobs and geographic breakouts, and the results will include data for Northwest, Southwest, metro Tulsa, and metro Oklahoma City.  Any Oklahoma hospices that would like to participate in this brief (and free!) study, can obtain additional information from Rosanne Zabka via email at  The Oklahoma Hospice study deadline is August 1st, with publication in October.

Watch the NAHC Member Listserv and NAHC Report for future updates.

HOSPICE NOTES is a National Association for Home Care & Hospice (NAHC) member benefit; to subscribe, go HERE.  Keep an eye on the NAHC Member Listserv and NAHC Report for updates on key hospice issues!  Subscribe HERE and HERE. Please have your NAHC member ID ready.

Notice to Hospices Failing Quality Reporting Requirements to be Mailed By June 29

The Centers for Medicare & Medicaid Services (CMS) has announced that by June 29, 2016, it expects to have mailed notifications to hospices that are not in compliance with Hospice Quality Reporting requirements for calendar year 2015, which will impact payments during fiscal year 2017. For CY 2015 (FY 2017) and after, CMS considers both Hospice Item Set (HIS) and Hospice CAHPS® survey data from January 1 through December 31 to determine the Annual Payment Update (APU) compliance threshold. If you receive a notice of non-compliance, you have the opportunity to submit a request for reconsideration on quality data submissions affecting your FY 2017 APU. See the instructions in your notification letter and on the Reconsideration Requests webpage. 

Hospices should also note that CMS plans to publish online a list of hospice providers that have met the quality reporting requirements. This publication will take place later this summer (after any reconsideration requests have been given full consideration). The National Association for Home Care & Hospice (NAHC) will keep hospice providers informed of further developments in this area via NAHC Report and the NAHC member listserv.

CMS Takes First Step in Public Reporting for Hospice with Online Hospice Data Directory
Hospices Urged to Check Accuracy of Information

The Centers for Medicare & Medicaid Services (CMS) announced earlier this year as part of the FY2017 Proposed Hospice Rule and again during a recent Open Door Forum that as a first step in public reporting of hospice quality data it would post online a Hospice Data Directory providing the Hospice Agency dataset, which contains a list of all hospices certified by Medicare and high-level demographic data for each agency. The Hospice Data Directory is now available here, and contains the following agency data:

  • Provider name
  • Complete address
  • Ownership type
  • CMS Certification Number (CCN)
  • Profit status
  • Date of original CMS certification

Please note that the Hospice Data Directory does not include any quality data.
Notice to Hospice Providers: All of the information in the Hospice Data Directory comes from the CMS Automated Survey Processing Environment (ASPEN). If your agency’s data is not listed in the database, is incorrect, or has changed, contact your Regional Office (RO) Coordinator. A RO Coordinators list is also included with the Hospice Data Directory.

CMS referenced the Hospice Data Directory as first step taken to publicly provide reported hospice data so that stakeholders can identify and locate hospices in a sortable, easy-to-use format. In addition to the new Hospice Data Directory, CMS is actively developing a CMS Hospice Compare site, which it expects to complete sometime in mid-2017. The CMS Hospice Compare site will provide valuable information regarding the quality of care provided by Medicare-certified hospice agencies by reporting the eligible Hospice Item Set (HIS) quality measures for each agency. To help providers prepare for public reporting, CMS will offer opportunities for stakeholder engagement and education prior to the release of the CMS Hospice Compare site. For additional information, regarding plans for publicly reporting hospice data please refer to the FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Proposed Rule

Hospices New to CAHPS: Hospice Survey Vendor Authorization Form Must be on File by July 15

The Centers for Medicare & Medicaid Services (CMS) has announced online that all hospices participating in the CAHPS Hospice Survey must authorize an approved CAHPS Hospice Survey vendor to submit data on the hospice’s behalf. Therefore, a CAHPS Hospice Survey Vendor Authorization Form must be completed and submitted. If the CAHPS Hospice Survey Project Team has not received this form from the hospice and a survey vendor attempts to submit the hospice’s survey data, the submission will be rejected by the CAHPS Hospice Survey Data Warehouse. In order for submission of CAHPS Hospice Survey data for Quarter 1 2016 and forward to be accepted, the hospice must have a CAHPS Hospice Survey Vendor Authorization Form on file with the RAND Corporation. If a hospice has not previously submitted the CAHPS Hospice Survey Vendor Authorization Form, the hospice must do so by July 15, 2016.

The CAHPS Hospice Survey Vendor Authorization Form must be signed and dated in the presence of a notary public, notarized, and sent to the RAND Corporation. Please refer to the Technical Specifications page of the CAHPS Hospice Survey Web site to download the form. Please note that once your organization authorizes a survey vendor, it is not necessary to provide additional notification unless your organization chooses to de-authorize its survey vendor.

If you are unsure if your organization has met this requirement, please contact the CAHPS Hospice Survey Project Team ( or 1-844-472-4621) or your survey vendor.

NAHC Advocacy Leads CMS to Rethink Electronic Submission of NOE/NOTR

In response to advocacy by the National Association for Home Care & Hospice (NAHC), the Centers for Medicare & Medicaid Services (CMS) is now actively pursuing efforts to allow for use of the institutional claim (837I) to submit hospice Notices of Election (NOEs) and related transactions via Electronic Data Interchange (EDI). This action, in CMS’ words, “would reduce, and potentially eliminate, problems with NOEs that result from errors during the Direct Data Entry (DDE) process.”  CMS’ Provider Billing Group is currently in discussions with its National Standards Group (NSG) in the Office of Enterprise Information to explore the potential for allowing hospices to submit NOEs via EDI using a non-standard implementation of the 837I transaction. Once the Provider Billing Group receives an opinion from NSG and has planned its next steps, it will provide a status report to NAHC.

Since October 2014, one of the most administratively burdensome and costly issues that hospices have dealt with has been meeting the timely filing requirements for NOE and Notices of Termination/Revocation (NOTR). Since that time the National Association for Home Care & Hospice (NAHC) and other stakeholders have worked diligently to address the growing number of problems associated with the timely filing policy. Last year NAHC and NHPCO jointly sponsored a hospice survey to help quantify NOE/NOTR-associated costs and financial losses, and the findings of the survey indicated that the financial impact of the requirement has been considerable. Over the last year NAHC has also sought a number of clarifications from CMS and its Medicare Administrative Contractors (MACs) with the goal of easing some of the negative consequences of using direct data entry (DDE) to meet these time-sensitive requirements. While some of these efforts have met with success, each -- on its own -- has made only a relatively modest impact overall, and additional problems continue to emerge in this area.

In implementing the timely filing requirement as part of rulemaking during 2014, CMS stated that NOEs and NOTRs were required to be submitted via DDE as “limitations in electronic submission standards prevent the use of the 837I claim format for this purpose,” but CMS requested input from the hospice industry regarding how electronic submission of NOEs and other transactions might be feasible. Beginning in mid-2015, NAHC began researching the potential for submission of these notices via EDI by exploring the means by which it could initiate development of the electronic submission standards for the NOE/NOTR. However, based on analysis, NAHC soon came to the conclusion that new submission standards may not be necessary since NOE/NOTR are not claims under the Health Insurance Portability and Accountability Act (HIPAA) and therefore should not be subject to the HIPAA transaction submission standards. In a subsequent discussion with CMS Provider Billing Group staff, NAHC discovered that if development of special transaction submission standards for the NOE/NOTR were not necessary, the process for allowing EDI submission of NOE/NOTR would be significantly less complex than had previously been thought by CMS.

Most recently NAHC wrote to Sean Cavanaugh, Director of the Center for Medicare, urging that CMS take action to allow for submission of NOE/NOTR via EDI and providing its analysis of why HIPAA transaction standards are not needed to allow for submission via EDI.  In a response from the Center for Medicare’s Provider Billing Group, Director Diane Kovach states,

“Your research into this question and the findings you share in your letter are gratefully received. My claims processing staff reviewed the material [you sent] and believes that our previous understanding on this subject may have been based on incomplete or inaccurate information. You note that the NOE is not a Health Insurance Portability and Accountability Act-covered transaction. It may be feasible for CMS and hospices to develop trading partner agreements to exchange data using a non-standard implementation of the 837I transaction. This would require CMS to develop a companion guide for NOE transition and for hospices to agree to the voluntary adoption of that companion guide.

“In order to assure that any step we take meets all the necessary requirements, I have instructed my staff to review this possible course of action with the National Standards Group (NSG) in CMS’ Office of Enterprise Information. When we receive an opinion from NSG and have considered our next steps, we will communicate the result to you.”

NAHC will provide future updates on this important issue through the NAHC member listserv and in NAHC Report.

NAHC Submits Comments on FY2017 Proposed Hospice Payment, Quality Regulations

On April 21, 2016, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (CMS-1652-P), the proposed Medicare hospice payment and policy rule for fiscal year (FY) 2017. Since that time, the National Association for Home Care & Hospice (NAHC) sought input and conducted numerous discussions with hospice stakeholders on aspects of the proposed rule, and submitted comments on June 20, 2016. Given that the FY2016 rule made significant payment and policy changes for hospice, it came as no surprise that the FY2017 proposed hospice payment rule placed most of its emphasis on next steps for the Hospice Quality Reporting Program (HQRP). In keeping with the content of the proposed rule, NAHC’s comments also place predominant emphasis on planned changes to the HQRP but also provide general comments related to hospice utilization and other trends discussed in the rule. Following is a summary of comments submitted by NAHC to CMS.

Hospice Utilization, Research and Analyses, Monitoring Payment Reform.  NAHC notes in its comments that growth in utilization of hospice services has slowed dramatically and requests that CMS provide additional detail that helps to identify the cause(s) of this slowdown so as to determine whether access to care is being impaired. NAHC also requests information on outcomes related to CMS’ previously announced referrals of hospices to Program Integrity and other oversight bodies (these referrals were the result of data analyses conducted related to payment reform). NAHC also notes the significant increase in hospice claims submitted with multiple diagnoses and posits that this will likely continue to improve since the Hospice PEPPER now provides hospices agency-specific data on the percent of claims that they have submitted that include only one diagnosis.

CMS includes as part of the proposed rule discussion of hospice’s role in Medicare end-of-life spending (including pre-hospice spending) and spending outside of hospice while patients are on a hospice election.  CMS found that patients with the longest lengths of stay have lower pre-hospice Medicare spending than those on hospice service for shorter lengths of time, but that overall Medicare spending for these longer stay patients tends to be higher than spending for those on hospice care for a shorter period of time. NAHC points out in its comments that it is oftentimes more difficult to predict life expectancy for longer-stay hospice patients due to their terminal diagnosis (Alzheimer’s, neurological disorders), and prior to hospice service they likely receive a mix of services weighted heavily toward personal and supportive services, which are frequently financed privately or under Medicaid. With election of hospice care the patient is then eligible for coverage of some of these services as part of the bundle of covered services. NAHC also cautions against movement toward a case-mix based hospice payment system and expresses support for payment refinements that help to incentivize appropriate timing on enrollment for hospice. Further, NAHC expresses support for monitoring of the impact of payment reform on hospices with a high proportion of short-stay patients. If the most recent payment refinements are affecting these providers negatively, CMS should work toward addressing this. NAHC also underscores the need for advancements related to processing of Notices of Election and Notices of Termination/Revocation so that patient status on hospice care is recorded in the Common Working File (CWF) on a more timely basis.

Updates to the HQRP: NAHC expresses support CMS’ recognition of the importance of the variety of hospice disciplines as part of its measures pair “Hospice Visits When Death is Imminent”, but relative to the measure cautions against creation of an environment that drives unnecessary visits. NAHC recommends that bereavement coordinators and volunteers be included as part of the measures when it undergoes revisions and urges that CMS develop a definition of a visit (for purposes of these measures) that is somewhat different from the definition used for claims submission. This would mean that post mortem visits, social worker phone calls, and other services would be included as part of that definition. CMS would be required to make changes to the measure numerator but NAHC believes that it is warranted.  NAHC advises that any calculations made from these measures be risk-adjusted to reflect a patient and/or family’s right to decline visits in order to maintain privacy.

NAHC raises several issues related to the Hospice Item Set (HIS) Composite measure, including advising that the scores should be risk-adjusted to reflect patients that are on service for short periods of time. In such cases, hospices must have the freedom to prioritize response to immediate needs, and may not be able to deliver all seven care processes in instances where a very short length of stay ends in death. Further, NAHC is concerned that public reporting of the Composite measures without sufficient explanation of the difference between process and outcome measures could mislead consumers, and indicates it might be appropriate to wait to publicly report the Composite measures until such time as the Hospice CAHPS findings can be reported. NAHC also expresses support for the Medicare Payment Advisory Commission’s recommendations that CMS pursue hospice outcome measures and actively eliminate measures that are no longer considered good measures of quality of care.

In its comments NAHC generally supports plans to create a hospice comprehensive patient assessment instrument but asks that CMS seek stakeholder input on the instrument throughout its development. NAHC also encourages CMS to consider options for development of measures that reflect quality of care at different points across the length of stay rather than just looking at patient admission and discharge as is currently the plan. NAHC also expresses concern that the new instrument will likely be completed by skilled staff at the time of care delivery so cost estimates must take that into account.

NAHC also provides some comment on star ratings for hospice, urging that CMS not utilize a bell curve for ranking of hospice programs as this type of ranking is not generally understood by the public. The full text of NAHC’s comments to CMS on the FY2017 proposed hospice payment rule is available here.

CMS to Survey for Compliance with 2012 Life Safety Code Starting November 1, 2016
New Standards Applicable to Hospice Inpatient Facilities

As reported previously, the Centers for Medicare & Medicaid Services (CMS) has amended the fire safety standards applicable to specific Medicare and Medicaid-participating facilities (including hospice inpatient facilities) by adopting the 2012 edition of the Life Safety Code-NFPA 101 (LSC), eliminating references to earlier editions of the Life Safety Code, and adopting the 2012 edition of the Health Care Facilities Code-NFPA 99 (HCFC) with some exceptions.

On June 20, 2016, the CMS Survey and Certification Group sent a Memorandum (S&C: 16-29-LSC) alerting all State Survey Agency Directors that these changes have been adopted and that CMS will begin surveying for compliance with the new LSC and HCFC requirements effective November 1, 2016. CMS will offer an online transitional training course for existing LSC surveyors to provide an update on the new requirements; this course will be available beginning September 2, 2016, on the CMS Surveyor Training Website. Additionally, CMS plans to update the ASPEN survey tracking program and CMS Fire Safety Forms (2786) prior to the November 1, 2016, survey start date. Additional surveyor training materials will also be updated to reflect the changes.

Surveyors will continue to use current process, tags and forms until November 1, 2016. In instances where the survey process identifies deficiencies that would be compliant under the 2012 LSC, a facility may verify compliance with the 2012 LSC as an acceptable plan of correction and the deficiency should not be cited.

Additional NAHC Report coverage of these changes is available here and here.

Office of the Inspector General (OIG) Releases Mid Year Report for 2016

In May, the OIG released the 2016 mid-year report.  In it the OIG summarizes the work completed thus far this year and indicates what work is yet to be completed in 2016.  Throughout the report, there is reference to hospice and to home health.  The following was stated regarding Medicare A & B:

OIG has focused its Medicare oversight efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. Future planning efforts for FY 2016 and beyond will include: additional oversight of hospice care, including oversight of certification surveys and hospice-worker licensure requirements; oversight of SNFs’ compliance with patient admission requirements; and evaluation of CMS’s Fraud Prevention System.
See the full report here.

Palmetto — Some Cost Reports Not Recognized as Timely Cause Payment Delays

Palmetto has indicated that it has halted payment for some home health and hospice agencies due to not receiving the agency’s cost report by June 7.  Some of these actions are in error. 

If you are seeking confirmation of receipt of your cost report that was received by Palmetto prior to June 7, 2016, send an email to Please include your PTAN, NPI, reporting period, date you submitted your cost report and, if possible, proof of delivery.  You may also call 803-763-1251 and leave a voicemail with the same information.

If your cost report was received on or after June 7, 2016, it is considered late and subject to payment suspension. Payments will not be resumed until the cost report is received and determined to be acceptable. The acceptance determination may take up to 30 days to complete from date of filing. This is in accordance with CMS instructions at CMS Pub. 100-06, Chapter 8, Section 10.3


In this section, Hospice Notes provides links to articles that have been published in NAHC Report, NAHC’s daily electronic newsletter, since Hospice Notes’ most recent publication.

Senator Wyden Speaks on the Importance of Tackling Chronic Illness, Updating the Medicare Guarantee, June 21, 2016

HHS Nondiscrimination Rule Includes New Notice Requirements for Providers, June 15, 2016

Rep. Jenkins Discusses the Importance of the Medicare Patient Access to Hospice Act at Ways and Means Health Subcommittee Hearing on Improving Medicare, June 14, 2016

MedPAC Submits Comments on FY2017 Proposed Rule on Hospice Payment, Quality, June 13, 2016

Home Care and Hospice Salary & Benefits Studies Currently Underway, June 9, 2016

Senate Labor-HHS Appropriations Subcommittee Approves Funding Legislation, June 8, 2016

LCAO Sends Recommendations to DNC and RNC Platform Committees, June 8, 2016

GAO Announces Newly Appointed MedPAC Members, June 6, 2016

Hospice PEPPER Training Session Recording Now Available, June 6, 2016

CMS Highlights Medicaid Resources for Zika Virus Prevention and Response, June 3, 2016

Legislation Supporting Family Caregivers Introduced in U.S. Congress, June 3, 2016


For questions about Hospice Notes, please contact its editors or authors
Theresa Forster, Vice President for Hospice Policy & Programs
Katie Wehri, Hospice Operations Expert

Please note that some links used in the production of the Hospice Notes are time-sensitive. These links may expire or require registration or fee-based subscriptions in order to access.

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