1. National Hospice and Palliative Care Organization CGS Strategy Session NHPCO November 15, 2012 © NHPCO, November 2012

2. National Hospice and Palliative Care Organization CGS as Medicare Administrative Contractor  CGS has responsibility to conduct medical review in compliance with CMS contract  Began medical review process as probe in mid- 2011  Denial rate consistently high – 83 – 87% at submission  Current widespread edits include 549 unique provider numbers of 798 providers  68.8% of CGS providers

3. National Hospice and Palliative Care Organization EditEdit Parameters # of ADRs 10/1/2011 – 9/30/2012 5011T Primary diagnosis 294.8 (other persistent mental disorders) and 28 units billed, and length of stay greater than 240 days 24 5011W Length of stay greater than 6 months, and primary diagnosis of 331.0 (Alzheimer’s), 799.3 (debility) or 496 (COPD) 107 5037T Hospice claims with revenue code 651 (routine) and length of stay greater than 730 days 927 5048T Hospice claims based with length of stay greater than 999 days 295 5057T Hospice claims with revenue code 656 (general inpatient) with at least seven or more days in billing period 416 5091T Hospice claims with HCPCS codes Q5003 (care in LTC or NF) and Q5004 (care in SNF), primary diagnosis 799.3 (Debility) and length of stay greater than 180 days 721 5101T Length of stay greater than 180 days, and primary diagnosis of 331.0 (Alzheimer’s), 799.3 (Debility) or 496 (COPD) 3,923

4. National Hospice and Palliative Care Organization $ Amount of Denials  For period 11/1/2011 through 7/31/2012  1,614 claims reviewed  1,372 claims denied (84.86%)  $$ value of claims submitted: $7,158,702,84  $$ value of claims denied: $5,433,201.01  75.84% of $$ value of claims reviewed were denied

5. National Hospice and Palliative Care Organization Denial data needed  Help NHPCO with advocacy regarding CGS denials  Send information on denials received from CGS by your hospice to: regulatory@nhpco.org  Details are important  Language in the denial is important

6. National Hospice and Palliative Care Organization Summary of Denial Trends TechnicalClinical No valid electronic signatureLCDs not supported for dx Missing/incomplete NOE6 month prognosis not supported Certification – missing/incomplete information or not timely Medical necessity for hospice not supported Missing/incomplete face-to-faceProof of IDT meetings; no signed POC Too much respite provided in benefit period Hospitalist not listed as attending physician Data collected by NHPCO, September-October 2012

7. National Hospice and Palliative Care Organization NHPCO Advocacy  Ongoing conversations with CGS about edits and review process  Meeting with CGS after Thanksgiving  Questions about denials  Technical  Clinical  Timeliness of CGS response  Timeliness concerns with Maximus and impact on appeals

8. National Hospice and Palliative Care Organization Things Your Hospice Can Do  Log in to CGS to check ADRs at least weekly  Create a process that supports timely response to the medical record requests – maximum response time of 30 days  Conduct agency self-assessment  Length of stay  Eligibility for services  Documentation of continued eligibility  Medical review and ADRs are the “new normal”

9. National Hospice and Palliative Care Organization