Regulatory Changes

NPHI has identified high-impact regulatory changes. Changes in these areas would have an immediate, ameliorating effect on our budgets and ability to survive as high quality, not-for-profit providers for years to come.

Costly Recovery Audits: The limited resources of the not-for-profit hospices increase the burden associated with cumulative Additional Document Requests (ADRs). The withholding of payment for unresolved ADRs is financially crippling. Limiting multiple unresolved ADRs would offer some relief. We recommend reforming the parameters for triggering audits to target providers that are the true drivers of inappropriate behavior. We also recommend restraining the authority granted to auditors when reviewing programs that operate at low margins and whose metrics such as diagnosis mix among patients and PEPPER scores demonstrate consistency with the intent of the Medicare hospice benefit. NPHI also supports identifying ways to mitigate the financial risk associated with multiple unresolved ADRs on community-based, safety-net hospice providers that do not have high levels of reserves.

Continuous Care Timeframe: NPHI recommends the current continuous care timeframe change from midnight to midnight to a new time frame of noon to noon. NPHI also recommends that visits from other providers such as chaplains and home health aides count toward the continuous care timeframe.

Part D Drug Prior Authorization: Drugs in four categories that are used to treat common symptoms at the end-of-life, including pain and nausea, require costly prior authorizations. NPHI recommends reassessing this requirement to ensure timely access to critical medications.

Notice of Election (NOE) Time Frame: Effective October 1, 2014, hospice providers have a maximum of 5 days to have the NOE submitted and accepted by their Medicare contractor. The Medicare Administrative Contractor (MAC) has 15 days to respond and if the NOE is denied for any reason, the hospice is not paid for any days that the beneficiary has been on service. No retroactive claims are accepted, so no corrections can be filed. NPHI recommends that the MACs be made to respond to NOEs in the same abbreviated time frame as the hospices submit them – 5 days. If the MAC had a required time to respond to hospices, this would help to reduce lost revenue. Alternatively, the time in which the NOE had to be submitted by the hospices could be increased to 10 days but the MACs should be held to the same standard.