Hospice Coalition Questions and Answers: March 6, 2025
To: Hospice Coalition Members
From: Palmetto GBA Provider Outreach and Education (POE)
Date: March 6, 2025
Reports
Questions for Response
Provider Enrollment
1. Question: Per the website, Palmetto GBA is “experiencing longer than normal Medicare enrollment application processing times.” Please give insight into what those enrollment times are.
Question 1a: A new hospice is awaiting processing of their enrollment and assignment of a CMS Certification Number (CCN). We understand that after the certification survey is complete both the state survey agency and the Centers for Medicare & Medicaid Services (CMS) Regional Office participate in the process. Once the other two parties have completed their steps, what is the typical turnaround with Palmetto GBA to complete the enrollment process? We were told that it would take 6–9 months from the time of the survey to completion of enrollment. Is that now extended?
Answer: The typical turnaround time for Palmetto GBA to complete the enrollment process for a new hospice, after the state survey agency and the Centers for Medicare & Medicaid Services (CMS) Regional Office have completed their steps, can vary. Historically, it has been estimated to take around 6–9 months from the time of the certification survey to the completion of enrollment but is approximately 6–12 months currently. Processing times can be influenced by various factors, including the current workload, any additional documentation requirements, and potential delays in communication between the parties involved.
Question 1b: A hospice entered a partnership with another organization and two hospices are now under one company with a new tax ID and separate CMS Certification Numbers (CCNs). If all documents are in order when the change of ownership (CHOW) is submitted, what is the typical turnaround time and how does that differ from “standard processing times” that you strive to have?
Answer: When a hospice enters a partnership and undergoes a CHOW, the typical turnaround time for processing the CHOW, assuming all documents are in order, can vary. Generally, it may take around 60 days for the CHOW to be processed. However, this can depend on specific circumstances and the workload. The CHOW process can be more complex due to the need to verify new ownership details, Tax IDs, and ensure compliance with all regulatory requirements.
Medical Review
2. Question: During round one of Targeted Probe and Educate (TPE), our hospice received a claim denial rate above the 20 percent threshold. We are appealing the denials because we think the patients were eligible for service. We know that CMS requires Medicare Administrative Contractors (MACs) to monitor appeals. The Medicare Program Integrity Manual (IOM Pub. 100-08), Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, at 3.7.4 — Tracking Appeals (PDF), states, “The MACs shall track and evaluate the results of appeals. It is not an efficient use of medical review resources to deny claims that are routinely reversed upon appeal.”
Question 2a: Does Palmetto GBA monitor claims through the appeal process and consider reversals prior to round two or round three beginning for a hospice?
Answer: Palmetto GBA identifies any appeals during the effectiveness process, if there are decision reversals based on the appeal, this information is captured. If there is an appeal found fully favorable after education and prior to the next round, providers can submit a request for a TPE recalculation.
Question 2b: If denial reversals are considered in a recalculation, is that only at the Redetermination level or is it also through the Reconsideration and Administrative Law Judge (ALJ) levels if those appeal results are available before the subsequent round begins?
Answer: Effectiveness considers information provided at the first and second appeal levels. As the subsequent appeal levels take time, Palmetto GBA continues with the TPE process of education and subsequent round implementation.
Question 2c: If the appeals are not used for a recalculation, can a hospice ask to have their denial rate recalculated before the subsequent round begins? Not progressing to the next round would alleviate additional audit burden on the provider. And if a provider is referred to CMS at any point, those appeal results are considered by CMS in determining further action.
Answer: Appeals are taken into consideration. If the appeal is not finalized prior to the subsequent round, a Hospice can ask for a recalculation to occur.
3. Question: How does Palmetto GBA decide when to begin pulling claims for review after a TPE Notice is sent? A hospice received 20 Additional Documentation Requests (ADRs) for the Bene Sharing TPE just a week after receiving notice of the TPE. Only 20 days later, they started receiving ADRs for a post-payment TPE for Hospice Length of Stay (LOS) Greater Than 365 Days with claims going back to early 2023. They did not know they were under that TPE until they received the ADRs. They found the TPE Notice in eServices that their billing staff had missed months earlier.
Question 3a. Why would Palmetto GBA wait so long to pull the claims for the post-payment ADRs when they did not need to wait for new claims to be filed?
Answer: Several factors play a role in when claims are selected. As previously discussed in prior meetings, Palmetto GBA has a limit on the number of claims audited per day. Providers have also reached out to Palmetto GBA to delay an audit because of burden. Typically, Palmetto GBA will start the ADR process within 2–3 days after a notice is sent.
Question 3b. Why issue those ADRs during a current TPE for another topic? It seems that since they had waited for months, they could have waited longer to avoid two TPEs at once.
Reply: Is there a specific question related to a process?
Question 3c. The Bene Sharing TPE has a 90-day response time for record submission, but the Long LOS is only 45 days. If one TPE is eligible for an extended response time, why not both? The hospice has a significant burden trying to respond to two different TPEs at once.
Answer: Response timeframes are extended based on requirements from CMS during times of emergency relief. Depending on when the ADR was issued will result in when the response is due.
4. Question: We need additional information on the Beneficiary Sharing TPE which was initiated initially in Spring 2024. After advocacy from hospices and other stakeholders, Palmetto GBA agreed to pause the audit process and retract the notices in July 2024. Due to the timing of the initial notice and the retraction, some hospices had already submitted records, and the medical review process continued for those. If a hospice had zero to two denials, well below the 20% threshold, why are they now having to go through the Bene Sharing TPE again when they have already been reviewed?
Answer: Palmetto GBA stopped the previous audit and released all associated claims that were not reviewed. As the audit was stopped all providers were removed from the audit, via letter. Prior to starting the audit, analysis was conducted to identify providers for selection. If a provider was previously selected and subsequently selected, they continue to be an outlier.
5. Question: Hospice data was analyzed again to determine those hospices with a higher volume of shared beneficiaries and the Bene Sharing TPE audits resumed at the end of 2024.
Question 5a: What was the reporting period for the data that was analyzed for the current TPE audit? Was it Fiscal Year 2024 (Oct, 1, 2023 – Sept. 30, 2024) or something different?
Answer: Palmetto GBA does not provide this level of information as not all providers selected would fall within a specific date range. When providers are selected, Palmetto GBA typically uses a three to six month date range of recent claims data.
Question 5b: Numerous hospices have reported that the claims selected for ADR represent only one or two patients who had prior hospice services. With that small sample size of shared beneficiaries, how can this TPE process achieve its intended purpose to determine if a hospice’s management of transfers or discharges is improper? Reviewing the medical record of only one of the hospices may not give insight into why a patient transferred or was served by one hospice, discharged, and readmitted to another.
Answer: Palmetto GBA utilized beneficiary sharing to identify hospices for a comprehensive review.
Based on our analysis to identify providers, beneficiaries shared directly between two providers were determined. For each provider identified as a "From" provider, the total number of distinct beneficiaries shared directly was computed and the total disbursement received during the period the provider was acting as a sharing "From" Provider was also computed. We calculated the total distinct beneficiaries served and total disbursement received for payment for an identified period.
As reference, a total of 2,130 unique providers (From Provider IDs) were identified to have a beneficiary directly move hospice care to another provider for the payment period analyzed. Of these, 426 providers were flagged as outliers at jurisdiction level for percentage shared beneficiary.
As an example, a total of 162 beneficiaries moved hospice care from Provider “A” to Provider “B”, and Provider “A” and “B” were flagged as outliers at the state level for percent shared beneficiary and provider disbursement. In a secondary example Provider “A” shared beneficiaries directly with 124 different providers, meaning only Provider “A” would be flagged as an outlier.
Question 5c: Is the TPE audit focusing on the hospice that has a high volume of transfers (or discharges) or on the hospice accepting those patients or both?
Answer: Both
Question 5d: What are the bene-sharing ratios that create outliers for accepting a beneficiary that has previously received care from another hospice? How many admissions does a hospice have to have for this activity to be considered an outlier?
Answer: Those ratios change based on the period sampled as well as providers included. As an example, if we utilize the period of Jan. 1, 2024 – May 31, 2024, we may have 200 unique providers that have shared beneficiaries. Of the providers in the period, 100 of them may have one shared beneficiary and could be below the average shared beneficiary count. Those providers would be excluded from selection.
Question 5e: For those hospice claims without shared beneficiaries, what data are you finding that corresponds to bene-sharing claims that identifies what claims are to be pulled?
Answer: The claims selected are randomly selected for review. Once the provider is identified as an outlier for beneficiary sharing, Palmetto GBA is conducting a traditional review.
Question 5f: For those hospice claims without shared beneficiaries, what are you learning from those claims that help you to determine if a hospice’s management of transfers or discharges is improper?
Answer: Many providers will start a new benefit period instead of continuing with the current benefit period when a beneficiary is transferred. This throws off the timing requirements of the face-to-face, CTI, narrative, etc., resulting in denials.
Question 5g: Some hospices are in an area with multiple hospices that do not always provide quality care which causes patients to transfer to a quality hospice. How can a hospice avoid being unfairly identified as an outlier when they are simply trying to meet the needs of patients and families?
Answer: Unfortunately, the patient discharge codes do not account for displeasure of hospice services with a provider.
Question 5g: Similarly, a hospice with an inpatient facility may have a higher volume of transfers in because of another hospice in the area not having the ability to provide the GIP level of care. Is that variable factored in when analyzing the data?
Answer: Please see the above answer.
6. Question: At the time of admission and election of the Medicare Hospice Benefit, a patient chose a community attending physician. That community physician agreed to serve as attending physician and gave the verbal certification timely within two days of election. But when the written certification of terminal illness (CTI) form was sent to him, he did not sign it despite several attempts to obtain a signature.
Question 6a: Since the hospice has the documented verbal certification, can the hospice physician sign in lieu of the community attending physician?
Answer: No. The attending must sign the CTI or a signed change in designated attending physician statement must be completed by the patient (or representative). The effective date for the change should be on the signed statement. CMS IOM 100-02, Chapter 9, Section 40.1.3.1 (PDF) states,
"The statement must include the date the change is to be effective, the date that the statement is signed, and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed."
Question 6b: If the patient agrees to a change in attending in writing before the hospice submits the first claim, can the new community attending physician sign the initial written certification with no billing issues imposed?
Answer: The change of attending would become effective per the effective date on the signed change in designated attending physician statement. The newly assigned attending per the signed statement would adhere to established hospice CTI timeframes per the regulations. CMS IOM 100-02, Chapter 9, Section 40.1.3.1 (PDF) states,
"If a patient (or representative) wants to change his or her designated attending physician, he or she must follow a procedure similar to that which currently exists for changing the designated hospice. Specifically, the patient (or representative) must file a signed statement with the hospice that identifies the new attending physician in enough detail so that it is clear which physician, NP, or PA was designated as the new attending physician."
Question 6c: Or if the patient agrees to a change in attending in writing before the hospice submits the first claim and opts for a hospice attending physician, would that obviate the need for a signed CTI by the community attending and there be no billing issues?
Answer: The attending must sign or a signed change in designated attending physician statement must be completed by the patient. The effective date for the change should be on the signed statement. CMS IOM 100-02, Chapter 9, Section 40.1.3.1 (PDF) states,
"The statement must include the date the change is to be effective, the date that the statement is signed, and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed.
"The date the change in designated attending physician statement is signed is the date that the CTI is valid, so it depends on when that was signed by patient (or representative). CTI from community attending is not necessary but could affect billing based on date signed."
Question 6d: Or if the patient agrees to a change in attending in writing before the hospice bills the first claim and chooses an APRN or PA from the community or the hospice as attending, would that obviate the need for a signed CTI by the attending and there be no billing issues?
Answer: Not sure. The APRN or PA would become the chosen attending upon the effective date on the signed change in designated attending physician statement. CMS IOM 100-04, Chapter 11, Section 10 (PDF) reads:
"Nurse practitioners or physician assistants serving as the attending physician may not certify or recertify the terminal illness. It all depends on the date change of attending form was signed, date signed is not specified. If the change of attending was completed days after SOC there will be denied DOS."
Question 6e: What billing issues does Palmetto GBA identify that may result with any of the above scenarios? Are all dates of service (DOS) billable in those situations?
Answer: Not all DOS are billable if the change of attending form is completed later during the DOS, after the hospice is unable to obtain CTI from community attending MD in initial/first BP. There will be noncovered days until a signed change in designated physician statement is completed by the patient (or representative).
Claims
7. Question: A hospice enters a Notice of Election (NOE) with the wrong start of care date and then uses the NOE coding with condition code D0 and occurrence code 56 to correct it.
Question 7a: Do they have to file an exception request when they file a claim?
Answer: The process to correct an erroneous hospice admission date on NOEs allows the received date of the original processed NOE to remain on record and avoid or reduce late NOE penalties. If the correction to the admission date results in the received date of the original NOE to be received within the five day timely filing period of the admission date, no exception request would be required.
If the correction to the admission date results in the original received date of the NOE to be late, the hospice may file an exception if they have good cause. For example, if an NOE were received on February 17, 2025, for an admission date of February 12, 2025, this NOE would be timely as currently processed. However, if the corrected NOE admission date is February 10, 2025, the NOE will be late after the correction and a late NOE penalty would be applied. (Resource: Process of correcting an NOE admission date is on page 5 of the Hospice Notice of Election TOB 8XA Job Aid — PDF.)
Question 7b: Do we have to file a new NOE if we are making the correction after the five day window for submission of the NOE?
Answer: No. An admission date correction NOE is still applicable after five day timely NOE filing period expires.
8. Question: We have a Medicare beneficiary whose claims were being paid, but then the claims started to Return to Provider (RTP) due to the wrong Medicare Beneficiary Identifier (MBI) number. The patient has died, and we cannot get the new MBI number from them.
Question 8a: Why will the Palmetto GBA representative not give us the new number when we call?
Answer: The current MBI is a piece of disclosure needed to release any Protected Health Information (PHI) information. The eServices MBI Lookup Tool will provide a deceased beneficiary’s MBI if the Medicare beneficiary information entered is valid and the date of death was within the last four years. (Resource: Can I obtain an MBI for a deceased beneficiary using the eServices MBI Lookup Tool?).
Question 8b: How do we find the new MBI? And what do we do if we do not have the patient’s Social Security Number (SSN)?
Answer: Palmetto GBA cannot answer this question. The hospice must decide on a process to avoid this issue. (Resource: Medicare Beneficiary Identifier — MBI.)
9. Question: We thought that NOEs could be submitted during system dark days, but when we tried to submit an NOE, we could not. Now when checking the Medicare inquiry screen, the receipt day is showing late. When we file for the exception, we are informed this is the provider's fault and no exception is given. Why is the exception not granted when the system was not available? What do we need to do to receive the exception in these situations?
Answer: In the great majority of cases, the five day timely filing period allows enough time to submit NOEs on a day when Medicare systems are available (i.e., the period allows for ("dark days"). Additionally, the receipt date is typically applied to the NOE immediately upon submission to Medicare systems, so subsequent dark days would not affect the determination of timeliness. However, if the hospice can provide documentation showing an NOE is submitted on the day before a dark day period and the NOE does not receive a receipt date until the day following the dark days, the contractor shall grant an exception to the timely filing requirement. CMS expects these cases to be rare.
Resource: Section 20.1.1 - Notice of Election (NOE) of the Medicare Claims Processing Manual (PDF). Electronic claims transmitted directly to a contractor by 5 p.m. in the contractor’s time zone, or by its closing time if it routinely closes between 4 p.m. and 5 p.m., must likewise be considered as received on that day even if the contractor does not upload or process the data until a later date.
The DDE system is available to providers as follows:
- Monday to Friday: 6 a.m. to 8 p.m. ET
- Saturday: 6 a.m. to 4 p.m. ET
- Sunday: Not available
General
10. Question: We understand that Palmetto GBA is required to set up individual account receivables for all Recovery Audit Contractor (RAC) adjustments that create overpayments. Hospices need transparency with these balances to reconcile accounts timely, especially given that these accounts are subject to interest accruals.
Question 10a: Can Palmetto GBA please clarify when RAC denied claims begin accruing interest?
Answer: RAC overpayments follow the 935 Overpayment Recoupment Process and accrue interest on any unpaid balance on the 31st day. (Resource: Section 935 Overpayment Recoupment Process.)
Question 10b: Currently, demand letters issued from Palmetto GBA are not available for providers in eServices. Failure to receive these letters timely prevents providers from issuing payments accurately. Can Palmetto GBA offer these demand letters via eServices so providers can receive timely communication with accurate balances?
Answer: The RAC overpayment demand letters are issued by HIGLAS (Healthcare Integrated General Ledger Accounting System) and are available in eServices, via eDelivery. (Resource: Overpayment Demand Letters Available in eServices.)
Question 10c: If demand letters cannot be issued through eServices, which department within Palmetto GBA could best assist providers with questions related to their RAC account balances?
Answer: RAC overpayment demand letters are available in eServices. Additionally, providers can view overpayment balance information via our eServices’ online portal. Previously, providers did not have the ability to view their active overpayment balances and had to contact the Provider Contact Center (PCC) to obtain this information.
To access this data, providers will enter either an accounts receivable (AR) transaction number or a demand letter number. The portal will display real-time status of your AR or demand letter balances to include the:
- Principal AR balance
- Interest AR balance
- Total AR balance
Resource: Overpayment Demand Letters Available in eServices.
11. Question: According to Medicare guidelines, it is the Receiving Provider B's responsibility to ensure the transfer days are consistent with the Transferring Provider A through the Change of Hospice form.
Question 11a: How does a hospice manage the situation where the Transferring Provider A continued billing patient past the agreed-upon date, which is after the beneficiary has started receiving services from Provider B?
Answer: The transfer date must be agreed upon before the transfer takes place. The transfer date must be the same date the beneficiary leaves one hospice and received by the other hospice. Either the transferring/discharging or receiving hospice may assist the beneficiary/authorized representative with initiating the transfer. In either case, the transfer requirements must be met.
If the hospices cannot work out a solution, a billing dispute may be submitted. At least three contacts must be made with the other hospice, and the following must be documented:
- The method of communication (e.g., email, telephone, fax)
- Dates/times of contact with the other hospice
- The name individual with whom you communicated at the hospice
Unanswered communications are not acceptable. Ensure that you document the response from the other hospice to ensure both hospices agree with the terms of the transfer.
Question 11b: How does a hospice Provider (B) manage the situation where the patient’s transfer was delayed, and the transfer form is no longer valid?
Answer: An updated transfer agreement would be best. (Resource: Hospice Transfer Requirements.)
12. Question: What process do we need to use when following up on a Billing Dispute Resolution? For example, we submitted the form on July 8, 2024. Despite multiple calls for updates, there is no update on resolution as of December 9, 2024. Question 4 in the Hospice Coalition Questions and Answers: February 29, 2024, states that while there is no set timeline for the Billing Dispute Resolution process, Palmetto GBA strives to complete disputes within 60 business days of receipt.
Question 12a: If Palmetto GBA aims to complete disputes in 60 business days, why are we told to wait an additional 45 days before we call again for an update? Do we have to wait that long?
Answer: We strive to have them completely within 60 business days. However, due to the volume of disputes received, the resolution time is currently longer.
Question 12b: When should we ask to have our questions about the Dispute elevated to the next tier for assistance?
Answer: If you have received confirmation that your dispute was received and is processing, which is the status. You will receive notification once finalized.
Question 12c: Is it appropriate to use the Ask the Contractor (ACT) call for these type questions?
Answer: Specific questions about the statuses of a provider’s inquiries, claims, etc. cannot be addressed in mass educational events.