Arkansas State Hospice and Palliative Care Association
Arkansas State Hospice and Palliative Care Association
Linda Swart – Palmetto Coalition Representative.
As part of this report you will find all of the attachments given in the sessions.
This forum was not as helpful as previous sessions as the agenda was really too full for a one day forum. I feel most evaluations will reflect this and hopefully it will be better next year. My evaluation reflected that we have addressed some of these issues for the past three years and are our presentation this year is the same as the past years with no resolution or even a move toward a resolution shown. The other problem to me is the agenda was so tight there was no time for the participants to discuss fully and to ask questions and there were less present from CMS (although there w to back up the speakers so most questions had to be referred by completing a note and handing it in. I really don’t know when those questions will be answered.
Agenda:
Medicare Part A & B will be transitioning from Fiscal Intermediaries processing of claims to MAC’s (Medicare Administrative Contractors). The number will reduce from 60 contractors down to 23. The FI’s are competing against each other for these Contracts with CMS stating the bids will not be necessarily be awarded to the lowest bid. These bids are for DME’s and Medicare A & B. The bids are awarded by the dates as shown on the Exhibit A-b. According to this chart AR is in Jurisdiction C which is Region 7 and will be awarded July –September 2007. Palmetto has made a bid for all of Region C. There are some problems noted already on this bid process as some of Palmetto’s current regions will not be awarded until July of 2008. CMS had not seen a problem with this until this meeting. No resolution was offered but they indicated they would study the situation and let us know. Exhibit A-a is the Transmittal of the sunset of the Policies Nominations for an Intermediary and the Provider Requests for a Change of Intermediary.
Exhibit B shows the 2007 Medicaid Survey results from Palmetto Coalition States. The request was made for CMS to work with the various states to encourage them to offer Medicaid benefits more equitably across the states. CMS cannot dictate to the states but could work proactively to educate in some of the problem areas and some of the problem areas entail the Hospice benefit which should mirror the Medicare benefit. Exhibit-B-a is the actual survey answers as provided by each state.
Cherry presented the very same presentation she has done for the past three years. This is one of the areas where CMS keeps indicating they are going to help but have not done anything to move in that direction. See Exhibit C for her presentation. An official request was made to establish a workgroup of hospice providers/nursing home providers and CMS representatives to work on a solution.
The purpose of her presentation was to educate CMS on the need to either eliminate or update the Cap appropriately. See Exhibit D for her Power Point Presentation.
CMS indicated they would pass this information on to higher authorities.
ABN- Issue to the patient and family 2 days prior to last covered day. Not required for transfers or revocations.
Deliver the ABN in person whenever possible and get a signed copy for your medical chart. If the patient or family refuses to sign the have the nurse document the refusal on the ABN copy and keep it in the medical chart. If the family needing to sign the ABN is out of state then deliver by fax or overnight mail and you must make a note of the procedure you have followed on the ABN and keep your copy in the medical record. ALWAYS designate one person in your agency to be the liaison for the QIO and inform your on-call nurses who this person is. REMEMBER the QIO has 48 hours to give their decision and this includes weekends and holidays.
CMS Transmittal #594 states the Fiscal Intermediary Reviewer should not contradict the QIO. Much discussion on this issue as there has been so many medical denials and more hospice discharges due to the denials that we can foresee the QIO receiving an appeal that disagrees with the hospice determination to discharge. At times the Attending Physician says keep the patient and the Medical Director says discharge. CMS did not give any answer much to the dismay of the Medical Directors in attendance. They did say they would refer the issue and to write the questions out with specific cases deleting the PHI. No handout was provided.
Exhibit E – Going Beyond Diagnosis.
Dr. Feliciano’s presentation centered on the ICF and centered on how the utilization of the ICF would prevent medical denials for the longer length of stays they were seeing in the Non-Cancer patients as you would be better able to document the changes in the patient’s condition. He is willing to take this presentation “on the road” and in fact has presented at several state conferences. (He did indicate to me later that he would be more than willing to come to Arkansas and present to Hospice Medical Directors in the evening and then do a workshop for any Hospice attendees if we would pay his airfare and his hotel. It is not reimbursable by CMS as all the FI’s are not utilizing the ICF.) I HIGHLY RECOMMEND ASHPCA GETTING HIM ON OUR AGENDA FOR THE SPRING 08 CONFERENCE EVEN IF IT MAKES IT A 2-DAY. I don’t suppose it could be tagged onto our ASHPCA Fall Conference???
Exhibit F is attached for your study. His presentation can be summarized by this statement. If you have an Alzheimer’s patient identify every condition you can and utilize and apply the ICF to each of those conditions. This is the key to identifying when the Alzheimer’s patient is appropriate for hospice. CMS had praise for both Dr. Feliciano and Dr. Policzer’s presentations.
See Exhibit G. Brad's focus was that Alzheimer’s disease is the hardest of diseases to predict prognosis. By utilizing the LCD’s and the ICF together the patients receive hospice care appropriately. Part of the reason there were several presentations to CMS regarding Alzheimer’s disease was to show that there is an appropriate time to admit these patients and this disease is on the rise so we must be proactive in learning how to identify appropriate patients now as the need will only increase. If we don’t learn to identify them and patients are admitted inappropriately then there is danger that CMS will not allow Alzheimer’s patients to have hospice. (Some hospices were reported to have Alzheimer’s patients for 10+ years.)
Although this was a very important topic we were very behind in schedule so her presentation was very rapid fire. I made notes on the handout as much as possible for you. Otherwise, she indicated they have new investigations underway on live discharges from hospice. A marker is placed on the claims to identify the number of live discharges a provider has in order to see if patients are being admitted inappropriately and then discharged a few months down the road. They actually have 13 new data elements they are marking from submitted claims. She did not list the 13 but from her presentation I know three more of them are GIP, Continuous Care and % of non-CA patients served. Always make sure CC is documented as a Crisis. Complaints have increased for 12 in 2005 to 50 in 2006 and she indicated 2007 looks as though it will be even higher.
Note in the Exhibit the Peer Comparison by State. This shows the Avg. Los for all patients in that State. Four states have over 100 days ALOS per patient. Three of those states are shown in the chart. 45 providers in those three states have received letters from Tricenturion that their charts and claims are being monitored for education purposes.
The last two agenda items were not discussed as the meeting time was past time to dismiss.
I have also included in your packet the latest CMS Region IV Organizational Chart labeled Exhibit K
