Avoid Denial of Claims With Proper Documentation: New Education Series on the Medicare Hospice Certification Requirement

The top reason Medicare denies hospice claims centers on improper documentation, which is projected to result in $2.9 billion in improper payments. In this new series, we’ll share information, tips, videos, and continuing medical education trainings to help reduce claim denials. Starting with proper certification of terminal illness (CTI) is critical.

When is CTI needed?

For patients to receive hospice coverage under Medicare, providers must submit CTI documentation at these intervals:

• Benefit period 1: the first 90 days

• Benefit period 2: the next 90 days

• Benefit periods 3+: each subsequent 60-day period

What should be included in the CTI?

• Statement of terminal illness: simple statement that the patient’s life expectancy is 6 months or less (≤ 6) if the terminal illness runs its normal course

• Clinical findings that support terminal illness: specific clinical findings (e.g., patient diagnosis and prognosis, laboratory results, rapid decline in patient status) to support a life expectancy of ≤ 6 months

• Hospice benefit period(s): specific “from” and “through” dates (i.e., MM/DD/YY to MM/DD/YY) for each period of hospice care

• Narrative: synthesis of the patient’s individual clinical circumstances that support a life expectancy of ≤ 6 months and a statement attesting that the physician wrote the narrative based on their review of the patient’s medical record or an examination

• Physician signature and date: legible physician signature and date (e.g., Chris Smith MD, MM/DD/YY) directly below the narrative; if illegible, type or print the name below the signature.

• Face-to-face encounter and attestation: face-to-face visit by a hospice physician or hospice nurse practitioner

Click to review full ‘Physician Certification’ resource sheet.

CMS Final Rule Cracks Down on MA Plan Marketing, Prior Authorizations

McKnight’s Home Care | By Diane Eastabrook
 
The Centers for Medicare & Medicaid Services issued a final Medicare Advantage rule late Wednesday that cracks down on shady marketing by MA plans and ensures MA enrollees get the same access to care as those enrolled in traditional Medicare plans.
 
The new rule, which reflects the proposed rule released in February, requires health insurers to mention an MA plan’s name in all television advertising and prohibits private health insurers from using Medicare logos or imagery that could be misconstrued as an endorsement by the federal government. The rule also requires additional guidelines for insurance agents and brokers.
 
“The confusion that often arises and the changes some enrollees will often make to their detriment in getting healthcare are things we want to try to avoid,” Health and Human Services Secretary Xavier Becerra told reporters during a press briefing.
 
The new rule also tries to eliminate barriers to accessing care by ensuring that all MA plans comply with coverage regulations that apply to both MA and traditional fee-for-service Medicare plans. It also streamlines the prior authorization process and requires MA plans to provide consistent care throughout a beneficiary’s course of treatment.
 
“MA plans cannot add additional hoops to go through before an MA enrollee can access care they are entitled to under Medicare,” CMS Deputy Administrator Meena Seshamani, MD, told reporters. 
 
HHS also is expanding access to behavioral health services under the final rule and including a health equity index in MA Star Ratings to ensure underserved populations have equal access to care. 
 
The tougher MA regulations come less than a week after CMS updated 2024 rates for MA plans, offering a 3.32% payment bump and phasing in a risk adjustment model over three years. Becerra said both actions will put “appropriate guardrails in place” to make sure consumers are protected and MA plans are adequately funded to provide care.
 
MA plans — which account for just under half of the nation’s 65 million Medicare beneficiaries — have come under increased scrutiny in recent months. The plans have been criticized for using aggressive marketing tactics to enroll beneficiaries and for falling short on coverage. An Office of Inspector General report last year found the plans often deny or delay services covered under Medicare. A more recent report by Kaiser Family Foundation found MA plans denied 6% of prior authorizations in 2021.

CDC: Adults Need Only One Updated COVID Booster Shot, for Now

McKnight’s Home Care | By Alicia Lasek

The Centers for Disease Control and Prevention does not recommend more than one updated COVID-19 booster shot at this time for adults who have completed their primary series of vaccinations, according to guidance information updated this week.

The Food and Drug Administration in August authorized omicron-targeting vaccines made by Pfizer-BioNTech and Moderna as preferred COVID booster shots. Unlike the original monovalent vaccines, these vaccines are bivalent, protecting against both the original virus that causes COVID-19 and omicron variants BA.4 and BA.5.

In February, the CDC’s independent vaccine advisers decided that current evidence did not support more than one yearly dose of the newer, bivalent vaccines, including for older adults and other groups vulnerable to severe disease. That decision was largely based on a lack of existing data on the efficacy of multiple doses. But the CDC itself did not confirm a stance on the issue at the time.

The new CDC guidance appears a FAQ webpage directed at the public, as reported by the San Francisco Chronicle Tuesday. The CDC answers the hypothetical question of whether one should receive more than a single, updated booster by stating, “No. Currently, CDC recommends one updated COVID-19 booster dose” for everyone aged 5 years and older, and for certain younger children.

“If you have completed your updated booster dose, you are currently up to date. There is not a recommendation to get another updated booster dose,” it added in another post update March 2. In addition, the Food and Drug Administration has not authorized more than one shot.

Health officials appear to be leaning toward an emphasis on preventing severe disease as a priority over preventing infections, the Chronicle noted.

“The bottom line is that there is some waning of protection for those who got boosters more than six months ago and haven’t had an intervening infection,” Bob Wachter, MD,  chair of medicine at the University of California, San Francisco, told the news outlet. “[T]he level of protection versus severe infection continues to be fairly high, good enough that people who aren’t at super high risk are probably fine waiting until a new booster comes out in the fall.”

Clinically fragile adults, such as some elderly adults and many nursing home residents remain high risk of severe outcomes from COVID-19.  

In the meantime, the World Health Organization’s vaccination advisory group also has adjusted its COVID-19 vaccination guidance. It now recommends that countries prioritize at-risk older adults and frontline healthcare workers, among other high-risk groups — for both initial shots and boosters. With immunity levels high from infections and vaccinations, there is no longer an urgent need to prioritize healthy younger adults and children for the shots, it announced Tuesday.

Veterans Health Care Decisions

Well over 90% of Veterans say they want to age in place. Aging in place is “the ability to live in your own home and community while staying safe, independent and comfortable – no matter your age, income, or ability level.”

The Department of Veterans Affairs (VA) has resources for Veterans, their families, and caregivers to help you age in place. When you visit www.va.gov/Geriatrics you’ll find information about:

• Home and Community Services
• Support for Caregivers
• How to Focus on What Matters to You
• Paying For Long Term Care
• Advance Care Planning
  • Getting Started
  • About Advance Directives
  • Choosing a Person to Make Decisions
  • Talking with Loved Ones
  • Group Visits
  • Other Types of Advance Care Planning
  • More Resources about Advance Care Planning

These resources provide more details and can guide decisions that reflect what matters most to Veterans and their loved ones:

• Video about Patient Priorities Care (about 4.5 minutes)
• My Health Priorities – What matters most in life and health is different for everyone. It may be harder to manage your health if you have multiple conditions. The more you and your health care team know about what matters most to you, the better you can work together to line up your health care decisions with your priorities.
• Veteran Decision Aid for Care at Home or in the Community – Helps Veterans think about what matters most when considering long term care choices.
• Caregiver Self-Assessment – Helps caregivers review their roles and responsibilities and evaluate their stress.

To learn more about services and resources for Veterans and their caregivers, visit www.va.gov/Geriatrics.