RAC Reviews May Have Slowed, but Claim Denials Continue To Grow

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Original story posted on: October 2, 2013

Auditors’ additional documentation requests (ADRs) have declined this summer in preparation for the Centers for Medicare & Medicaid Services’ (CMS’s) selection of and transition to a new recovery auditor exclusively responsible for durable medical equipment (DME), home health, and hospice audits. However, hospice denials continue to mount. 

Performant Recovery, Inc., the RAC for Region A, is the only auditor to post an extensive length-of-stay issue for hospice during this time, but the Medicare Administrative Contractors (MACs) and Comprehensive Error Rate Testing contractors (CERTs) also have focused on length of stay. Hospice providers must consider the possibility that their terminally ill patients may no longer have a terminal prognosis.

Many hospice providers have received denials following medical review because the documentation failed to support a patient’s terminal prognosis. To prevent this, hospice providers must ensure that they are following the guidelines in the local coverage determinations (LCDs) for terminal prognosis, in addition to meeting all of the technical components for the certification of terminal illness.

CMS considers a patient to be terminally ill if the medical prognosis is a life expectancy of six months or fewer if his or her illness runs its normal course. The Social Security Act specifies that the certification of terminal illness is based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the patient’s attending physician. Many of the denials for hospice claims are occurring due to the failure of the documentation reflecting the written certification and/or face-to-face encounter to include specific clinical findings supporting the required life expectancy. Providers must be aware of the guidelines included in the LCDs and ensure that the documentation in each patient’s record supports a terminal prognosis. If the patient improves and/or stabilizes to the level of no longer having a prognosis of six months or less to live, or if that patient no longer meets the criteria in the LCD, the patient should be discharged from the Medicare hospice benefit. 

Hospice providers often are reluctant to discharge their patients, citing concerns about the decline in the patient’s condition without the hospice services and the ongoing personal care and emotional support needs that the patient and their caregivers continue to have during any period of stabilization.  Providers must work with their staff and physicians to ensure that they prepare their patients for the lack of Medicare hospice coverage during this time. They must educate the patient and his or her family on the resources available to them upon discharge and the changes to their Medicare coverage, and providers must ensure that patients and their families know they may re-elect hospice if the patient’s clinical condition declines to the point that his or her life expectancy is six months or less again.

This issue will not be going away anytime soon, and it most likely will be one area of focus for the new Recovery Auditor. Hospice providers should be aware of the average length of stay for all of their patients and conduct an internal review of patient records for which the length of stay exceeds 180 days. Since a face-to-face encounter is required at this time, it is an opportune moment to include a review for compliance with the technical components of the certification of terminal illness (accurate certification dates, appropriate physician signatures and dates, timeliness, face-to-face encounter documentation, etc.), as well as to perform a review of the clinical documentation to ensure that it supports the patient’s terminal condition.

About the Author

Bonny Kohr (RN, CHCE, HCS-D) is the manager of clinical services for FR&R Health Consulting, Inc. She is a registered nurse, a certified homecare coding specialist, a certified homecare and hospice executive, and an American Health Information Management Association (AHIMA)-approved ICD-10 trainer. Prior to joining FR&R Healthcare Consulting, Inc., Bonny worked 23 years in home health care.   She provides clinical, operational, regulatory and reimbursement consulting services for home health, hospice, and other healthcare providers.

Contact the Author     

BKohr@frrcpas.com

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Bonny Kohr, RN, CHCE, HCS-D

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