CMS Hospice PEPPER Alert

Summary at a Glance

On April 5, 2023, the RELI Group, the CMS contractor for the Program for Evaluating Payment Patterns Electronic Report (PEPPER) released the Q4FY22 Hospice PEPPER. Each Hospice PEPPER summarizes claims data statistics (obtained from paid hospice Medicare UB-04 claims) for the most recent three federal fiscal years (the federal fiscal year spans October 1 through September 30). A hospice is compared to other hospices in three comparison groups:

• Nation
• MAC jurisdiction
• State

These comparisons enable a hospice to determine whether its results differ from other hospices and if it is at risk for improper Medicare payments.

Two new target measures have been added:

• Average Number of Medicare Part B Claims for Beneficiaries Residing at Home
• Average Number of Medicare Part B Claims for Beneficiaries Residing in an Assisted Living Facility, Nursing Facility, or Skilled Nursing Facility

The PEPPER contractor describes the reason for adding these two target measures:

Medicare could pay for the same items or services twice if nonhospice items and services are billed to Medicare when they should be covered by hospices. In February 2022, the OIG published “Medicare Payments of $6.6 Billion to Nonhospice Providers Over 10 Years for Items and Services Provided to Hospice Beneficiaries Suggest the Need for Increased Oversight” (A-09-20-03015).

In this report, it is noted that CMS confirmed “its ‘long-standing position [is] that services unrelated to the terminal illness and related conditions should be exceptional, unusual and rare given the comprehensive nature of the services covered under the Medicare hospice benefit’ (84 Fed. Reg. 38484, 38506 [Aug. 6, 2019]). All hospice-related services must be provided directly by the hospice or under arrangements with the hospice (42 CFR §§ 418.64 and 418.70).”

These PEPPER target areas were approved by CMS because they have been identified as being potentially at risk for improper Medicare payments.

DOWNLOAD YOUR HOSPICE PEPPER:

PEPPERs are available via PEPPER Resources Portal and can be accessed by the provider’s Chief Executive Officer, President, Administrator, Compliance Officer, or Quality Assurance/Performance Improvement Officer.

Hospice Claims Incorrectly Returned to Provider

NAHC

Some hospices are seeing claims Return to Provider (RTP) due to a problem with the attending physician’s National Provider Identifier (NPI).  Transmittal 11633/Change Request (CR) 12889 which instructs MACs to have an edit that validates the attending physician’s NPI includes hospice claims and should not.  The CR instructs MACs to validate the NPI in the Attending Physician field on a claim against the Provider Enrollment, Chain, and Ownership System (PECOS) file.  If the NPI is not found in the file, the claim will be returned to the provider.

However, attending physicians for hospice patients are not [yet] required to be PECOS enrolled so their NPI will not be in the PECOS file unless they are otherwise enrolled.  The FY 2024 hospice proposed rule includes a proposal that physicians certifying hospice care be PECOS enrolled or have a valid opt-out but that is not finalized.

Effective April 1, 2023 hospices that submit a claim where the attending physician’s NPI is not in the PECOS file, the NPI and last name do not match, or the claim has a date of service equal or greater than the termination date on the PECOS enrolled physician inquiry screen will see the claim RTP.  NAHC reached out to CMS about this issue and CMS confirmed that the edit is being applied inappropriately.

New instructions are being sent to the Medicare Administrative Contractors (MACs) to fix the issue.  A specific timeframe is not provided but CMS indicated the instructions should reach the MACs within 30 days and the MACs will then have ten business days to implement. However, PalmettoGBA has already posted to its website that within ten days (April 17, 2023) all hospice claims RTP’d due to a problem with the attending physician’s NPI will be returned to processing and there is no additional provider action necessary.

Any hospice claims impacted prior to the fix being implemented will need to resubmit the claim.  Hospice providers in other MAC jurisdictions should watch their MAC’s website and communication channels for more information.

The Potential Risks of ChatGPT and Other Generative AI

JDSpura | By Baker Hostetler

“Shall we play a game?” Those innocuous words “spoken” by Matthew Broderick’s computer in John Badham’s sci-fi techno-thriller War Games stunned audiences at the time. A computer that could “talk” and “think” and engage in conversation?!? This was the height of science fiction. Well, with the recent release of generative artificial intelligence (AI) tools, specifically in the form of ChatGPT and other predictive natural language processing (NLP) algorithms, science fiction has once again become reality.

Companies from Microsoft to Google and Instacart to Kayak have begun to incorporate and build upon this technology, originally developed by OpenAI. These tools can be incredibly beneficial to businesses, but they also carry risks.

Before we dive in to how generative AI can assist brands and companies, let’s first peel back the layers and understand – at a basic level – what ChatGPT is.

ChatGPT stands for Chat Generative Pre-trained Transformer. Let’s break that down:

• Chat refers to the interface that allows for interaction with the model using natural language prompts.
• Generative refers to a category of AI model that produces new output based on a given input. In practice this means that the “input” of a user query can generate the “output” of text, images, and audio answers.
• Pre-trained refers to the fact that the model has already been trained on a vast data set to teach it to predict the next word in a given sequence.
• Transformer refers to the architecture of the neural network (machine learning algorithms) upon which ChatGPT is based. It is this architecture that allows the computer to process natural language.

Importantly, ChatGPT and other generative AI are not omniscient; they cannot think, understand, or feel. They are merely software – lines of computer code – programmed to generate natural language replies in response to text and image prompts. They work by predicting the next word in a given text string based on patterns “learned” from the data on which they have been trained.

In late March, OpenAI released an API (application programming interface) to select businesses to allow them to incorporate the AI technology into their own websites and apps via plugins. Using these plugins, brands have been able to harness the power of ChatGPT to help consumers book travel, make restaurant reservations, and create curated product recommendations.

Currently, the ChatGPT plugins have been tasked with relatively basic functions – essentially providing high-level search tools in the form of an interactive chatbot. See, for example, the video Expedia released on Twitter to show how its ChatGPT plugin operates.

Brands have also begun to use generative AI tools to help with:

• Coding – generating and building source code and analyzing mistakes within the code
• Content Creation – generating blog posts, social media posts, targeted email campaigns and video scripts
• Data Analysis – analyzing large data sets and synthesizing the information into easily digestible bullet points
• Market Research – generating a list of key players in any industry along with products and services
• Product Descriptions – generating bulk descriptions for e-commerce sites where product catalogs are frequently updated
• Search Engine Optimization (SEO) – generating copy that includes keywords and meta descriptions that search engines can look for when ranking pages

ChatGPT and other generative AI tools come with risks, and any business use of them should be done carefully and cautiously.

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5 Home Health Leaders Weigh In On The Growth Mistakes They See Providers Making

Home Health Care News | By Joyce Famakinwa | April 12, 2023
 
The pursuit of growth is a never-ending journey for home health providers, and there are plenty of ways to err on that pursuit. 
 
Many leaders, through observation and first-hand experience, are able to recognize what should be avoided for companies that are aiming to accelerate. 
 
To get a better understanding of what home health operators need to know when it comes to the right and wrong way to grow, Home Health Care News asked several home health leaders to weigh in. 
 
According to them, the lack of proper training, failure to embrace payer diversification and not taking patient experience into account are all examples of errors that can be detrimental to a company’s growth plans. 
 
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