On April 19, 2019, CMS issued the FY2020 Hospice Proposed Rule. The following is a brief summary of the rule and what it could mean to hospice agencies.

FY2020 Hospice Proposed Rule

In this rule, CMS proposes to rebase the FY2020 per diem payment rates for Continuous Home Care (CHC), Inpatient Respite Care (IRC), and General Inpatient (GIP) levels of care based on their analysis of claims and cost report data, which shows the Hospice average cost per day of care is greater than Medicare reimbursement. To offset the increases in Medicare payments for these three levels of care, CMS proposes to reduce the Routine Home Care (RHC) level of care rate by -2.71% to maintain overall budget neutrality.

Next, in an effort to maintain the most up-to-date data and increase payment accuracy, CMS is proposing to use current year hospital wage index values, instead of the one-year lag that currently exists with using prior fiscal year data for the computation of the hospice wage index.

Additionally, this rule proposes to modify the hospice election statement by requiring an addendum that includes information aimed at increasing coverage transparency for patients under a hospice election.

Finally, the rule proposes changes to the Hospice Quality Reporting Program. CMS estimates that the aggregate impact of the payment provisions in this proposed rule would result in an estimated increase of $540 million in payments to hospices, resulting from the hospice payment update percentage of 2.7 percent for FY 2020.

Comments on this proposal are due no later than 5 p.m. on June 18, 2019. Details on the provisions in this rule are shown below.

Proposed FY2020 Payment Rates

CMS is soliciting comments on the proposal to rebase the rates for CHC, IRC, and GIP, and whether rebasing the payment amounts for these levels of care could “create an adverse incentive for providers to inappropriately steer patients to a higher, more specialized level of care when that level of care is not medically indicated.”

Early discussions of the proposed FY2020 payment rates have raised concerns about the CMS rationale surrounding an increase to three levels of care that are less utilized in hospice and a decrease to RHC, which is the highest used level of care in hospice. RHC is being referred to as the “bread and butter” of hospice care and reducing the payment rate for this level of care due to budget neutrality for increases in levels of care that are less utilized is causing concern for adverse impacts to hospices and subsequently, appropriate access to care for patients.

Also, CMS has placed high scrutiny on hospice improper use of GIP, which should only be used for management of pain when it cannot be done in the home. Hospices feel this action by CMS poses a conflict with CMS messaging for using those levels of care appropriately but yet reducing payment for the level of care that is most appropriate. This might also incentivize hospices to adversely utilize the other levels of care when they are not appropriate. It’s expected that there will be many comments to this proposal by industry organizations, hospices, and other stakeholders.

Proposed FY2020 Wage Index (Elimination of the 1-year lag)

CMS proposes to change the fiscal year used to calculate the hospice wage index by using current year pre-classified hospital wage index data versus using the prior fiscal year for the hospital wage index calculation. CMS has already changed the wage index year for other post-acute care providers to include home health (HH) and skilled nursing facility (SNF) providers and invites comments on this proposal to adjust the hospice wage index as well. The proposed wage index applicable for FY2020 (October 1, 2019 – September 20, 2020) can be found here.

The anticipated impact on Medicare hospice payments, due to the change in the wage impact methodology would vary by provider characteristics and can be found in Table 11 of the proposed rule. CMS has also posted spreadsheets with hospice specific impacts, which vary based on geographical location to the CMS website here.

Hospice Cap Amount

The proposed hospice cap amount for the FY 2020 cap year will be $29,993.99, which is equal to the FY 2019 cap amount updated by the proposed FY 2020 hospice payment update percentage of 2.7%.

Hospice Election Statement Content and Addition of a Proposed Addendum

To address numerous concerns related to Medicare payments that are made for hospice patients outside of the Medicare Hospice benefit after the patient elects the hospice benefit, CMS is proposing modifications to the hospice patient election statement content requirements and a new addendum (submitted upon patient request) to ensure patients are being adequately informed about the scope of services covered under the Medicare Hospice benefit and whether the patient rights are being fully promoted and protected.

Similar to the existing patient election statement, hospices can develop and design the new addendum to meet their needs but CMS does propose that the addendum be entitled “Patient Notification of Hospice Non-Covered Items, Services and Drugs” as well as proposes specific content.  However, different from the election statement, hospices would be expected to update the hospice addendum with changes in the conditions, items, services and /or drugs listed on the addendum that occur after the hospice election and during the course of hospice care and have it signed and dated by the beneficiary. CMS is also soliciting comments on the appropriate timeframe to provide the requested Election Statement addendum, which is currently proposed to be provided within 48 hours of the patient, caregiver and/or family request.

CMS is proposing that the election statement addendum content requirements be added to the regulation text at §418.24 and become a condition of payment. Specifics on the Hospice Election Statement content modifications and the Proposed Addendum content are documented on pages 25-26 of the proposed rule.

Role of Hospice and Coordination of Care

CMS has issued a Request for Information (RFI) on the interaction of the hospice benefit and various alternative care delivery models, the impact on the provision of hospice care and any lessons learned that CMS should consider for the future design of the Medicare hospice benefit. CMS states that the questions and complexities that have arisen surrounding including the hospice benefit into Medicare Advantage are indicative of the operational considerations that would need to be addressed around any long-term programmatic change such as ACOs and other payment models.

Proposed Hospice Quality Reporting Program (HQRP) Changes

CMS is not proposing any new claims-based or outcome measures at this time, however, they are soliciting public comments and suggestions related to ideas for future claims-based and outcome measure concepts and quality measures in the HQRP that could also be tied to the goals of the Meaningful Measure initiative. Other HQRP mentions in the proposed rule include:

  • A comprehensive hospice assessment tool (formerly known as HEART) continues to be under development. CMS will keep stakeholders engaged via open door forums, webinars, and other sub-regulatory means.
    • Impact: There are not yet any publicized dates for the implementation of this tool but it is expected it will be in pilot testing in CY 2020 with a formal rulemaking process to follow. This is expected to be a significant effort and impact for vendors and hospice providers since a mandated assessment tool currently doesn’t exist for Hospice.
  • As early as FY2020, providers will be migrating to a new internet Quality Improvement and Evaluation System (iQIES), replacing the current QIES and ASAP system for Hospice Item Set (HIS) submission and enabling real-time upgrades. Public notification of the details will begin on October 1, 2019.
  • The current CAHPS survey participation requirements have been proposed to extend for FY 2023 and all future years.
  • The current CAHPS volume-based exemption has been proposed to extend for all future years. Starting with FY 2022, CMS proposes to provide an automatic exemption to any hospice that (1) is an active agency and (2) according to CMS data sources has served less than a total of 50 unique decedents/caregivers in the reference year.
  • The process measure “Hospice Visits when Deaths is Imminent” (Measure 1 of the pair) met the requirements of scientific acceptability and will be publicly reported in FY 2019; However, measure 2 of the pair, does not meet the readiness standard for public reporting at this time and will not be publicly reported until further testing can be performed. A date has not been set for public reporting of measure 2; however, both measures are still available for private agency viewing via the Certification and Survey Provider Enhanced Reporting (CASPER) Quality Management system.
  • More details were provided regarding how the data from the Public Use Files (PUF) will be displayed on the Hospice Compare website. The PUF data, along with text explaining the purpose and uses of this information, will be displayed under a new “General Information” section this summer. This new section will precede the “Family Experience of Care” section and will include data such as levels of care provided, average daily census by diagnosis, total percentage of primary diagnoses served, and location of care.
  • Additionally, CMS proposes to post information from other publicly available government data to the Hospice Compare website in the future, such as the US Census Bureau, CDC, and National Institute of Health.

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