Hospice Payment Reform
With the Center for Medicare and Medicaid Services (CMS) Regulation CMS-1629-F, CMS implements hospice payment reform for all hospice agencies beginning on January 1, 2016. There are 2 primary components to this reform:
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A two-tier daily rate for patients under RHC acuity, depending on the number of days a patient has been receiving hospice care |
Payment Reform tab
The new Payment Reform tab (in Administration > Financial > Insurance Codes) contains the following sections:
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Allows you to enable the SIA logic starting from a defined date. SIA identifies the dollar amount to be paid for each unit, or each 15-minute service interval, of the visit. It enables hospice agencies to be eligible for a new type of revenue by Medicare (based on the continuous care hourly rate and paid according to individual units with a maximum of 4 hours per day) for direct patient care services provided to patients under RHC acuity by RNs or MSWs during the last 7 days of a patient's life. The SIA window contains 4 columns: Effective Date, Gross Rate, Net Rate, and Labor %. To see an example of this window with the default values, see the Payment Reform tab screenshot below.
The SIA amount is calculated only for payers who report direct patient services and only if values are specified in the SIA table. SIA is supported only with the correct Direct Patient Care (DPC) setup. For more information about DPC, see Hospice Direct Patient Care Services Setup.
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Allows you to enable the Gap Day Count logic. Beginning on the specified start date, you can track the start of hospice day counts for each patient who has an active admission on this date and who is insured by a particular payer. The claims generate per-diem RHC details starting from this date based on higher or lower reimbursement rates, as defined in the billing rates.
SIA specifies the number of days (60) that must pass between hospice admissions before a patient's hospice day count is reset to 1 and that patient is again eligible for higher reimbursement. This window contains 3 columns: Start Date, End Date, and Gap Day Count. To see an example of this window with the default values, see the Payment Reform tab screenshot below. For more information about the day count, see the Patient Day Count Report.
The Hospice Gap Day Count section is available for all benefit payers. If you are an existing Medicare Benefit payer, this section is filled in with 01-01-2016 as the Start Date and 60 as the Gap Day Count by default after you upgrade to version 15.3. If another Medicaid Benefit or Commercial Benefit insurance company wants to implement payment reform, you can add a new line for the start date and gap day count values for these payers. The logic for Commercial or Medicaid payers is the same as for Medicare, but other requirements might need additional code or configuration changes.
CMS-1629
The hospice payment reform consists of 2 primary changes to Medicare billing rules:
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By analyzing DPC services that are reported on a patient claim, CMS evaluates if an agency is eligible for an additional SIA payment if that claim is coded as a patient death. Services are eligible for payment only if all of the following criteria are met:
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The patient was receiving RHC during the last 7 days of life. |
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The services were provided by an RN or MSW. Visits from licensed nurse practitioners (LPNs) and phone calls from MSWs are excluded from reimbursement. |
To set up SIA-applicable services, click Administration > Financial > Insurance Codes > Service Codes/Contractor, select Social Worker from the left menu, and then click Qualified for Service Intensity Add-on.
Per the regulation, agencies do not submit a SIA dollar amount on a claim, but CMS reimburses agencies for this amount if eligible services are found.
To help agencies track their accounts receivable, Netsmart includes the SIA amount in the Accounts Receivable Report. SIA amounts are calculated only if the Service Intensity Add-On (SIA) table (in Administration > Financial > Insurance Codes > Payment Reform) is complete. The Service Intensity Add-On (SIA) table is available only for Medicare Benefit payers. Services that have the Post Mortem Modifier (specified in Administration > Financial > Insurance Codes > Per Diem) are not eligible for SIA reimbursement.
To help agencies determine if patients are eligible for SIA payments, Netsmart Homecare includes the Service Intensity Add-On (SIA) Tracking Report (in Reports > Hospice), which identifies how many eligible service units a deceased patient received in the last 7 days of life. The report shows zero for patients who received no services during their last week. To view this report, the operator must have access enabled (in Administration> Configuration > Operators > [Select an operator] > Privileges: Hospice tab > Reports > Hospice).
Note: Netsmart Homecare created a new SQL table, CLAIM_DETAIL_SIA_PER_DIEM, as part of the SIA development process. However, the data within the table is not a one-to-one correlation to the SIA Tracking Report.
The following reports also identify potential SIA revenue:
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Accounts Receivable Report (Reports > Financial) |
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AR by Billing Month Report (Reports > Financial) |
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Billing Register Report (Claims > Process > Process A Cycle) |
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Revenue and Expense Report (Reports > Financial) |
The SIA reimbursement is available only for Medicare Benefit payers. Medicare pays hospice agencies a wage-indexed portion of $9.84 for each hospice unit (or $39.37/hour), up to 4 hours per day, for RN or MSW visits. The allowable per-day maximum number of units is 16. CMS wage indexes the SIA payment as it does level of care payments. To ensure that SIA payments are calculated correctly, enter the correct Hospice Wage Index for the location where your patient resides in Wage Index, and specify 10/01/2015 as the Effective Date in the CBSA codes (in Administration > Financial > CBSA/MSA Codes). SIA payments are in addition to routine level of care payment rates. For more information about these rates and wage indexing, see https://clientconnect.allscripts.com...october-1-2015.
When a patient dies, claims are retroactively adjusted to enable Medicare to cover the costs of hospice services rendered for up to 4 hours per day during the last 7 days of that patient's life.
To disable SIA logic, add a new line. Set the Effective Date to the date on which the logic is disabled, and specify 0 for Gross Rate and Net Rate.
For an example of how a SIA payment is determined, see "Service Intensity Add-On Payment (SIA) Example" in the ICD-10-CM/PCS Billing and Payment Frequently Asked Questions.
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Through claims-based research, CMS determined that agencies incur higher service costs during the first 60 days of a patient's hospice treatment. With hospice payment reform, CMS reimburses agencies at a higher rate for the first 60 days of RHC and a lower rate for subsequent days. All other levels of care are paid at their normal rates. This two-tier rate is defined for RHC in Administration > Financial > Billing Rates. To set up these rates, define the ellipsis only for the rates that bill RHC. For more information, see Billing Rates.
According to the regulation, CMS is required to track the number of days a patient has been in hospice care. Netsmart also recognizes that this day count data is valuable to agencies for financial forecasting purposes. To accommodate this need, the Patient Day Count window, which is launched from the Patient Day Count button (in Patient > General > Admission & Status) tracks the number of days a patient has been receiving hospice care at the time of admission or payer effective date, if applicable. The Effective Date and Start Date fields are prefilled automatically, but the Start Date value can be manually changed with the proper administrator-granted privileges. If you modify a value on the Admissions & Status or Pay Control windows, the application automatically updates the values in the Patient Day Count window. As a result, a message displays that asks you to validate the update. If your modifications affect closed claims, those claims are voided and replaced. The new Patient Day Count Report (in Reports > Hospice) shows the number of days that patients have received hospice care. For more information, see Calculate Patient Day Count.
Important: The Patient Day Count button on the Admissions & Status window is disabled if the Start Date in the Hospice Gap Day Count section of the Payment Reform tab is not set or if it is after the date of discharge or death for a corresponding payer (in Patient > Pay Control). If you are using payment reform functionality, verify that the Start Date is set correctly.
For an example of how Patient Day Count values are used for two-tiered RHC billing, see "Routine Home Care (RHC) Per Diem Rates Example" in the ICD-10-CM/PCS Billing and Payment Frequently Asked Questions. For information about setting up the billing rates for two-tiered RHC billing, see Billing Rates.
The Hospice Gap Day Count button is enabled on the Admissions & Status window for patients who have Medicare benefit insurance and at least 1 active admission as of the current date. This functionality identifies the number of days that must pass between Medicare hospice benefit elections for the patient's individual patient day count value to be reset to 1, including when a hospice patient revokes an election and is readmitted at a later date, or if there is a period of time during which Medicare Benefit was not the primary or CSP payer for the patient and is not present on the Pay Control record. The End Date turns off the Gap Day Count logic that was introduced with the 2016 hospice payment reform in the application. This functionality enables the hospice day count and the two-tiered RHC billing.
The day count function shows the number of days a patient has been receiving hospice care services at the start of admission. To view the results of a recalculation, go to Patient > General > Admissions & Status > Hospice Day Count for the individual patient or run the Patient Day Count Report. For more information about the Patient Day Count, see Calculate Patient Day Count or Patient Day Count Report.