Event Summary

Event/Question and Answer Summary

Event Summary

National Government Services conducted an ACT for hospice providers in J6 and JK on 9/28/2022. The session provided an opportunity for the hospice provider community to ask questions of any department within National Government Services. The J6/JK hospice agencies were also able to ask questions prior to the call and send follow-up questions after the call by emailing J6.provider.training@anthem.com.

Pre-submitted Question and Answer Summary

Please note that questions and answers may have been rewritten for clarity. In addition, any claim specific questions were answered directly with the hospice facility.

  1. I understand that NGS has an LCD for ALS but what LCD do you recommend we use for a patient who does not have ALS but has a terminal neurological condition? I know that Palmetto has less specific requirements for neurologic condition criteria and am trying to ensure that we are using the correct LCD.

    NGS has one LCD: Hospice - Determining Terminal Status L33393

    It is important to remember that LCDs are to be used as guidelines and are not a guarantee of coverage.

Questions Received During the ACT Session

  1. We have a beneficiary that is receiving hospice care, upon further review we realized that we missed a face to face and a recertification date due to provider/clerical error? I understand that this falls on the provider and that I cannot request payment from Medicare for these dates of service. The NOE was submitted to Medicare and the benefit period has been established in the CWF.

    My question is: after discharging the beneficiary from care due to missed face to face or missed recertification,
    1. (For sequential billing purposes only) Should I submit the claims for these dates of service as non-covered to Medicare and then close out/finalize this benefit period
    2. No, I Do not submit any billing at all to Medicare for these dates of service and I do need to file an 81D to remove this benefit period from the CWF?

Answer: When the recertification is not done timely, an OSC 77 must be reported to represent for the days that are provider-liable due to the late recertification. The OC 27 is reported with the date that the actual recertification was obtained.

The OC 27 will be reported on the initial claim. Since the recertification was obtained late, the OSC 77 will be reported to reflect the days that are not covered by Medicare. The OSC 77 start date will be the first day of the election period where the recertification was obtained late. The OSC 77 end date will be the day before the actual recertification was obtained. OC 27 will then reflect the date that the actual late recertification was obtained.

When a provider-liable period crosses a billing cycle, the OSC 77 will be reported on both claims that have provider-liable days. Therefore, the OSC 77 start date on the first claim that has provider-liable days will be the first day of the election period where the recertification was obtained late and the end date will be the last day of the billing period. The OSC 77 start date on the second claim will be the first day of the billing period, and the end date will be the day before the actual recertification was obtained. OC 27 will then reflect the date that the actual late recertification was obtained.

  1. We have a beneficiary that is currently on hospice, when the beneficiary signed onto hospice services, the consents were signed electing to use the hospice benefits provided by a primary payer ahead of Medicare. We were recently notified that the primary insurance coverage termed retroactively a few months ago. My question is pertaining to the actual consent form. Since the beneficiary is still on service with hospice, and the original consents were signed electing to use the benefits by the original primary payer which has now terminated retroactively do we:

    1. Need to discharge the beneficiary from hospice and readmit with new consents electing to use their Medicare Part A hospice benefits?
    2. Keep the beneficiary on service and just get new consents electing to use their Medicare Part A hospice benefits?
    3. Or no, we do not need to discharge and no we do not need to get new consents signed, we can continue with the care and begin billing Medicare directly.

Answer: Once the beneficiary signs the hospice election statement, Medicare should start receiving claims as well as the NOE claim to set up the record. These claims might be Medicare secondary claims or Medicare primary claims, depending on the circumstances. By doing this, the system is aware of the start of hospice care and submitting the claims creates that audit trail.

If the beneficiary elected hospice and at that time the beneficiary was covered by a GHP through an employer, you should bill that GHP as primary and when that insurer makes a payment or issues a denial, then the claim should be submitted as Medicare secondary. Even if the other insurer paid the claim in full, you should still submit the claim to Medicare. Once the hospice election begins, you want to be sure to submit any claims for that beneficiary. In the event the primary insurer stops paying on the claims, even taking back some previous payments, you will have that claim in the FISS system and then can make adjustments. Condition codes should be used on the adjustments, a condition code of D8 can be used to explain that the claim is changing from a Medicare secondary claim to a Medicare primary claim.

In addition, you will want to make sure the beneficiary’s MSPRC record at the CWF is updated with the termination date of when the primary payer terminated the beneficiary’s coverage. You can do this by contacting the BCRC and providing them with information on the insurer’s or employer’s letterhead that indicates when that coverage ended.

You will want to get the beneficiary’s claims into the system from start of care if you have not already done so. If the primary retroactively termed their coverage.

  1. How would we handle a similar situation regarding the consents where the beneficiary has since passed/is now deceased and the primary insurance has retroactively termed and is also now recouping the payments that were already paid to us. Can we begin billing Medicare directly?

    See response above.
  2. Can you please respond to the scenario below:

    Patient A

    BP #1 – 5/1 through 7/29 (90 days)
    BP #2 – 6/15 through 9/12 (90 days)

    When a hospice patient is discharged on 6/3, the patient loses the remainder of the 1st benefit period. Patient starts at 2nd BP if admitted again to hospice.

    BP #1 – 5/1 through 7/29 (90 days) transferred to another Hospice (no gap in care)
    BP #2 – 6/3 through the remainder of the BP #1 7/29 (90 days)

    When a patient is transferred, patient continues to finish the current BP.

    You are correct that if a patient transfers to another hospice facility that there should be no gap, the transfer and receipt of a transfer patient should occur on that same day. If the beneficiary is in their first 90 day benefit period and there is a discharge from a hospice and then an admit to a different some days later, then the benefit period ends for that first benefit period. When admitted to the second hospice, the beneficiary will begin their second 90 day benefit period.
  3. We have two hospice facilities. Between the two hospice agencies, we serve thousands of patients each year, and obviously a certain percentage of those patients are entering their 3rd or later benefit period when they admit to hospice thus requiring a F2F before they can be certified as hospice eligible.

    In all the written guidance that we’ve seen re: these admits which indicate there may be “exceptional circumstances” which would allow a hospice to admit a patient and complete the F2F within a day after admission, the only written guidance we’ve seen is an emergency weekend admit -or- when CMS systems are down. CMS systems being down has never prevented us from completing a required F2F, but we have had our fair share of emergency weekend admits where we’ve taken advantage of the “exceptional circumstances” allowance and complete the F2F on Monday.

    Our question is this:

    Would an emergency admission, due to unmanaged symptoms, done after normal working hours on a weeknight, qualify under the “exceptional circumstances” allowance, if the case is well-documented and the F2F is done the following day?

    Please see the following reference.

    CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Section 20.1 - Timing and Content of Certification

    "Timeframe exceptional circumstances for new hospice admissions in the third or later benefit period: In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period. For example, if the patient is an emergency weekend admission, it may be impossible for a hospice physician or NP to see the patient until the following Monday. Or, if CMS data systems are unavailable, the hospice may be unaware that the patient is in the third benefit period. In such documented cases, a face to face encounter which occurs within 2 days after admission will be considered to be timely. Additionally, for such documented exceptional cases, if the patient dies within 2 days of admission without a face to face encounter, a face to face encounter can be deemed as complete."

Posted 11/4/2022