Hospice Coalition Questions and Answers: February 29, 2024

Published 05/08/2024

To: Hospice Coalition Members
From: Palmetto GBA Provider Outreach and Education (POE)
Date: February 29, 2024

Reports

Questions for Response

General

1. Question: How can a hospice obtain the new Medicare Beneficiary Identifier (MBI) numbers for patients that have had compromised MBI numbers and were issued a new number without us having a Social Security Number (especially on patients who are deceased)?

Answer: To pass disclosure, the beneficiary’s Social Security Number, first and last name and date of birth are required to pass disclosure and receive a response using eServices’ MBI Lookup Tool. eServices Users may obtain an MBI if the Medicare beneficiary information entered is valid and the date of death was within the last four years. On June 13, 2020, the deceased beneficiary MBI Lookup was extended from 13 months to four years from the date the MBI inquiry is performed.

Resource: Can I obtain an MBI for a deceased beneficiary using the eServices MBI Lookup Tool? 

2. Question: Is there another system to use for MBI look ups when the eServices portal is down?

Answer: No. In the rare occurrence eServices is unavailable for multiple days and causes an NOE to be late, a late NOE exception may be requested when the NOE is late due to an MBI error. Effective May 15, 2023, for NOEs, A/B MAC MACs will not grant exceptions based on MBI changes that were accessible to the hospice more than two weeks prior to the admission date. Since current beneficiary identifier information is available to hospices in eServices’ MBI Lookup tab or other MAC’s provider portal, only changes that occur shortly before the admission are beyond the hospice’s control.

Resource: Home Health and Hospice Billing When a New Medicare Beneficiary Identifier Is Assigned. 

3. Question: CMS issued Change Request 13342 (PDF), Implement Edits on Hospice Claims, on October 26, 2023. The CR discusses the new edit to be effective May 1, 2024, to ensure that both the hospice physician and the attending physician, if any, are enrolled in or opted out of Medicare at the time they make the certification or recertification of hospice care for a patient. CMS states the Provider Enrollment Chain and Ownership System (PECOS) will create a new extract file a list of National Provider Identifiers (NPIs) that are eligible for certifying for Hospice care and send it to the Fiscal Intermediary Shared System (FISS). PECOS will be adding a new field "HOSPICE" to the FISS bi-weekly O&R (Ordering and Referring) file and will be sending all eligible hospice physicians to data.cms.gov in the "HOSPICE" field. 

If the physician only has to be enrolled in or opted out of Medicare, why is there a need to create a new category in the CMS database? If there is not an indicator in the "HOSPICE" field, but there is in one of the other columns, does that mean they cannot certify for hospice? How can they be approved for some services and not others?

Answer: The CMS database also stores the records of physician assistants, nurse practitioners and clinical nurse specialists who can certify and recertify beneficiaries for other benefits, but not for the Medicare Hospice Benefit.

4. Question: A hospice has issues with another hospice not completing its billing. By the time the issues are resolved with intervention by Palmetto GBA staff, the hospice’s claims are past timely filing. We have questions related to the dispute resolution process. By the time a hospice works with the transferring hospice, files a dispute resolution request, and all processes are complete, the second hospice’s claims are past timely filing. The hospice may or may not have its exception request approved.

a. What is the best way to request a timely filing override due to sequential billing? The Timely Filing Exception Request form does not have an applicable exception for this situation. Three choices related to Medicare status for the provider or the beneficiary. The other choice is “Administrative Error” which addresses a “system error” being corrected. The Supporting Evidence section even addresses describing how the provider’s error caused the failure to file within the usual time. The form doesn’t have a choice for “Other” and it appears the hospice has to say it made an error when it did not. Should they call the Provider Contact Center since the form options do not work?

Answer: With sequential billing, the second provider should call the Provider Contact Center (PCC) after its efforts fail with the first provider to have them back out of claims. The PCC representative can then send a ticket to have the first providers claims backed out because you can see in the system the provider has been cut off. There would be no delay.

b. What is the timeline for the Medicare Administrative Contractors (MAC) to assist with a billing dispute resolution?

Answer: There is no set timeline. We strive to complete disputes within 60 business days of receipt. However, some disputes may take longer due to having to work with both providers to resolve the dispute.

c. What should a hospice do when it is not their actions that have caused the claims to exceed the timely filing limit? 

Answer: The hospice should file the claims according to the hospice billing guidelines for late NOEs (if applicable) and add remarks to request the Timely Filing Extension on their claim. The remarks should be specific and include the date that the other hospice completed or corrected their billing, and their resubmission of the claims must be within 6 months of this date. Providers should call the PCC for any claim that does not receive the exception and/or timely filing override in these cases.

Resource: Checklist for Timely Filing Extension.

5. Question: How can a Notice of Transfer, Type of Bill (TOB) 8XC, be cancelled out or corrected? We have not had any luck with doing either of these.

Answer: As a reminder, an 8XC, does not get submitted until after the other provider has finalized their billing and occurrence code 27 (date of hospice certification or recertification) is not required on a transfer notice, unless the date of transfer is also the first day of the next benefit period. 

To cancel an 8XC all claims for dates of service after the transfer need to be canceled first. The hospice can then submit a Notice of Cancellation, TOB 8XD. The 8XD may not have any additional coding not required on it. The specific coding requirements are on the Hospice Notice of Cancellation job aid, linked below. Remarks are required. The steps to correct an erroneous transfer date on an 8XC are on page 5 of the Hospice Notice of Transfer job aid, linked below. 

Resources

6. Question: How can a hospice get an incorrect date of death updated on the Medicare CWF without getting the family involved?

Answer: There is no change in the process from Q&A #4 of the Hospice Coalition Questions and Answers: February 23, 2023 for incorrect CWF DOD issues and the article it references, Incorrect Data Posted to the Common Working File (CWF).

7. Question: We experience instances where a patient’s date of death is incorrect in the Social Security Administration (SSA) records and on the CWF. We work with the SSA to get it corrected. Our understanding is that the SSA communicates the change so it will be updated on the CWF. 

In some instances, we must wait up to six months between the SSA correction and the update on the CWF. During this time, we routinely contact the SSA, and they confirm the date is correct on their end and they can see it is not corrected on the CWF. When there is such a lag between the update at the SSA and the CWF, we are concerned about not being paid due to timely filing. Is there anything we should be doing differently to expedite the process, or is there any guidance we can provide the SSA when this happens? Is there a way to influence a timelier update by the CWF?

Answer: A MAC cannot answer this question. SSA must be contacted. The below resources may provide insight on how SSA updates the records they oversee and the terminology they use. 

Resources

8. Question: We recently acquired a home health agency which is operating under the same Tax Identification Number (TIN) as our hospice locations, but all have different NPIs. We received a Remittance Advice (RA) for one hospice NPI that has a provider adjustment on it listed as “-$188.41 FB- forwarding balance” with a date that is 17 days prior to the RA and an RA for the home health agency with a provider adjustment on it listed as “$188.41 E3-Witholding”’ with the date of June 30, 2024, which is five-and-a-half months in the future. 

The first 18 digits of the reference ID on each RA are the same. It looks like there is a takeback on the hospice NPI due to an outstanding takeback from the home health NPI. On the hospice side, we have not seen a takeback from one NPI reduce the payment of another NPI.

a. First, is the mixing of payments, i.e., recouping money from an NPI that was not reimbursed for that claim something that we can routinely expect now that we have both home health and hospice?

Answer: Rules allow CMS to hold providers and suppliers with the same tax ID number, regardless of their billing number or NPI number, liable for the debts of "affiliated providers." For example, one hospital in a hospital chain may owe money but lack the funds to repay. CMS can collect from any other hospital in the chain or from the parent company as long as the tax ID number is the same. Resource: Affiliated Providers and the Recoupment Process.

b. Why would there be a provider adjustment date on a January 17, 2024, RA that shows June 30, 2024?

Answer: The June 30, 2024, date is the fiscal year end date, not the adjustment date. This is an element that is part of the electronic RA file. This date can be ignored for RA posting purposes. The adjustment/withholding date is the date of the remit, January 17, 2024.

9. Question: A patient discharges alive and quickly readmits. Our Notice of Termination/Revocation (NOTR) for the previous admit and NOE for new admit are entered in DDE on the same day, both within the required timeframe of 5 days. The NOE (81A) processes before the NOTR (81B) and RTPs.

We filed a Notice of Election exception adjustment claim since both notices were timely and the hospice cannot control how the Medicare system processes these. Some of these are approved for exception and some are denied. It seems the approval depends on who reviews the claim instead of being based on the Medicare policy. Denials require a first level appeal, and again some of those are approved, and some are denied.

a. When an exception has been reviewed and approved, how do we ensure Medicare consistently reviews and approves these requests for the same exception on related claims moving forward? 

Answer: Late NOE exceptions are reviewed on a case-by-case basis. The hospice can refer to the DCN of the previous claim that had an approved exception and enter the same or similar remarks. Remember, the exception process is a limited appeal process and if the reviewer determines the remarks do not provide enough information, and we do not make assumptions as to what we believe the remarks are attempting to state, the hospice should appeal.

It is equally important that the notices be billed in sequential order. If not, the exception will be denied. Resource: Page 13 and 14 of the Hospice Notice of Election (NOE) Timely Filing & Exceptional Circumstances Guidelines (PDF).

b. Is there a specific remark or prior exception language that should be added to each claim? 

Answer: The hospice can refer to the claim DCN of the previous claim that had an approved exception. Resource: Hospice Notice of Election (NOE) Exception Examples (PDF).

Medical Review

10. Question: Many providers who utilize the NCLOS Comparative Billing Report (eCBR) as one of the many tools to assist in being proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines. The reports are usually available in eServices soon after the end of the six-month timeframe, so in April and October. The state-level reports for April 1 to September 30, 2023, were not posted until early December. The provider reports were not posted until the end of January, four months after the report period ended. Moving forward, can Palmetto GBA plan to return to the April and October posting timeframe?

Answer: Yes, as per our report, the issues with posting the latest NCLOS reports have been resolved and providers can expect to see the NCLOS eCBR return to the April and October posting timeframe.

11. Question: During the more recent TPE audits, Palmetto GBA has been reviewing 40 claims per hospice when available. When a hospice moves to Round 2 of the TPE, can they expect to have 40 additional claims audited? Or is there a possibility that 20 claims can be reviewed, and if the approval rate is high enough the hospice can be removed from audit as opposed to 40 claims being reviewed?

Answer: Sample sizes are determined by several factors. Currently contractors utilize the 20 to 40 claim sample as outlined for TPE requirements. Utilization, patient census, number of distinct outliers a provider is flagged for are some of the criteria used to identify sample size. During initial TPE implementation, Palmetto GBA identified a minimum sample size of 20 for hospices but adjusted to 30 and 40 claims to help reduce the number of audits per provider. As claims are randomly selected, sample sizes are determined prior to the probe and adjusted on an as need basis.

12. Question: We have noticed that some of the Local Coverage Determinations (LCDs) are being updated and continue to become more generic than in the past. When updates occurred in the past, a group of hospice physicians and clinicians from the Palmetto GBA region were pulled together to assist in the updates. Can you inform us on how and who participates in developing the revised guidance? Is there an opportunity for hospice representatives to work with the Palmetto GBA staff to review the LCDs and consider revisions?

Answer: There have not been recent updates to coverage changes in the hospice LCDs. Any changes that are made are listed in the “Revision History Information” section of the LCD, which includes the Revision History Date and Revision History Explanation. Most recent changes are to correct formatting and punctuation errors.

If there are to be changes to LCDs, they would go through the LCD Reconsideration Process which includes an open meeting and period of comment.

13. Question: How are the LCDs being used during the TPE reviews? It is our understanding that these are guidelines and not regulations. What direction is given to the reviewers about application of the LCDs.

Answer: Reviewers use the LCDs as a guideline. The entire record submitted for that date of service is used to determine if the documentation supports a prognosis of six months or less.

14. Question: What are the appropriate reasons that a hospice can refuse to take a transfer? For example, we refused a transfer due to inclement weather conditions and informed the original hospice of this. However, the original hospice moved forward and completed transfer paperwork. We were not able to visit until a few days later. CMS has stated that hospices have a right to deny admission to individuals for various reasons, such as if the hospice doesn’t have the capacity or resources to adequately meet the patient’s needs or if the patient doesn’t meet eligibility requirements. Do hospices have the same rights to refuse patient transfers as they do with patient admits? 

Answer: Hospices can refuse an admission at any time, including transfers. Refusing a transfer should be determined by the hospices on or before the transfer date to avoid disputes. 
 

Education Topics

Next Meeting: June 20, 2024


Was this article helpful?