In the midst of rising demand, costs, and sharpened regulatory scrutiny, many hospice providers are facing Medicare recertification review challenges that can seriously harm patients and families, as well as their own bottom lines.
The U.S. Centers for Medicare & Medicaid Services (CMS) requires hospices to recertify patients who have survived beyond their initial estimated life expectancy. If the agency denies the recertification claim, patients no longer receive the care they need, and the hospice no longer receives revenue for providing that care.
The appeals process for recertification denials is both costly and complex, requiring a substantial commitment of staff hours to complete with no guarantee that CMS will reverse their denial. Moreover, CMS sometimes takes 60 to 90 days to review the appeal, during which the patient is not receiving care and the hospice is not receiving reimbursement
“There are also human costs,” said Debra Beatty, R.N., B.S.N., senior solutions specialist with Optima Health Solutions, in a webinar developed by Home Health Care News. “Terminally ill patients get discharged early because of recertification denials. They leave hospice with unmanaged pain and emotional distress. They lose their support system, and they may have to enter a facility because the family can’t manage their symptoms at home.”
The leading cause of claims denial is a CMS determination that a diagnosis of terminal illness that will cause death within six months is not supported.
Patients who experience longer lengths of stay, such as those who suffer from chronic illnesses such as congestive heart failure, neurological conditions, or chronic obstructive pulmonary disease, are most often affected.
In rare cases, this is due to fraud. Often however, denials occur due to inadequate or incomplete documentation or missed deadlines, particularly missing or unsigned physician narrative statements and certifications of terminal illness.
“Your Medicare administrative contractor will base their judgement entirely on the documentation that you provide. Remember they will not see the patient,” Beatty said.
Staff education is a critical strategy. Staff need to know and understand CMS documentation and reporting requirements , and they need to have effective documentation practices.
“Educate your staff. I can’t emphasize that enough. If your staff are not painting a very good picture or not doing good documentation, then there is really nothing to compare when it comes time for recertifications,” Beatty explained. “You want to still be able to demonstrate that your patient is still eligible for the hospice benefit, and that their disease is still progressing.”
When staff are preparing the documentation they should refer to clinical indicators of decline, use quantitative measures, and provide evidence for observations about the patient’s condition. For example, include factors such as whether the patient is cachectic, non-ambulatory, or has a poor appetite. Supporting documentation such as as admission assessments or the progression of any comorbidities that could affect the patient’s life expectancy.
Hospice providers should begin planning for recertification as soon as they admit the patient to help avoid missed deadlines or any last minute scrambling to gather the documentation, according to the webinar. Beatty recommended beginning the recertification process at least 15 days before the patient’s benefit ends, and to schedule required face-to-face encounters at least 30 days in advance. CMS deadlines are based on calendar days, not business days.
In addition to effective practices, having the right tools can make a big difference.
“Make sure you have good software to support your reporting requirements; look for one that is built for hospices that provides dashboards to help staff manage recertification in real time,” Beatty said. “Streamline the process anyway that you can.”