Hospice 2019 Proposed Rule

Most hospices will like some aspects of the proposed rule for 2019 but some might not. These are just proposed changes for 2019, not what will actually happen. However, the report gives providers a preview of the mindset of regulators as to what the final rule will be later this year. Unlike some other providers such as home health agencies, hospices can expect to receive more – not less reimbursement in 2019. In exchange for the increase in reimbursement, hospices will be asked to do more, and may require some new internal operational changes.

Medicare has proposed to increase reimbursement to hospices by $340 million. Not all providers will see a large increase due to their location and associated wage index. Hospices should expect a minimum of 1.4% increase to a maximum of 3.4% increase in reimbursement for 2019.

In the proposed rule, CMS stated that utilization review will occur to see how reimbursement and care patterns are developing. In plain language – CMS is closely watching how providers are taking advantage of the current system. CMS wants to analyze how many visits are being done to simply increase reimbursement or if the patient genuinely needs skilled services. The other side of this is CMS is trying to review providers and see if less skilled services by home health aides are being utilized rather than skilled services of a nurse (see below). The end goal is to ensure hospices are not making too much money from the federal government and the American taxpayer.

Hospice is getting a potential boost to reimbursement is through a new add-on based on end of life services. CMS will analyze the data from claims to prove or disprove the concept that less-skilled services are substituted for skilled care provided to patients in their last few days of life when more intensive care is necessary. A new quality measure would be introduced to monitor this concept for data gathering and to determine if additional reimbursement at the end of a patient’s life will promote more skilled support services for both patients and their families.

Drug charges continue to be a big focus to CMS. CMS is going to drive and shift more resources to analyzing which Medicare program is paying for the drugs patients receive while under hospice care. Providers are required to foot the bill for drugs related to hospice care. CMS is determining if providers are shifting the cost of drugs from their organization to the government under Part D.

Patients that receive their Part D benefit drugs for non-terminal illnesses related conditions is still acceptable. Medicare is concerned that too many providers are shifting the costs of drugs to Part D rather than absorbing the cost as a condition of providing care to an end-of life patient.

Cost reports for hospices underwent changes back in 2016, but more changes could be coming. CMS is continuing to evaluate the need for more development and detailed data. CMS would like to continue to refine the processes used to analyze cost report data and requirements for reporting. We should expect continued cost report detail to be reported in the coming years as CMS tries to understand hospice growth and impacts of current reimbursement reforms.

While cost reports may require more information, CMS is looking at reducing the amount of detail required to be included with claims. CMS is suggesting that later this year, as part of the final rule, hospices would be allowed to group all drugs provided as one line item rather than breakout each drug on its own line. With this change, hospices would be allowed to include DME expenses with drug charges as one line item. Providers will still have the option to list drugs and DME as separate line charges, should they wish under the proposed rule.

Quality reporting is also expected to change if the new rule goes into effect. The proposed rule makes quality reporting permanent going forward. At the same time, the way data is reported to the public for certain measures would be grouped and reported as one item. CMS feels that 8 measures reported together could save provider resources and not harm the overall data available to consumers via Hospice Compare.

The 8 measures include:
✓ Safeguarding public health
✓ Patient-centered, meaningful care
✓ Outcomes
✓ Meet federal statue requirements
✓ Reduce compliance burdens on hospices
✓ Improvement – what can providers do better?
✓ Alternative payment models (Hint: Pay for Play)
✓ Continuum of Care and Multi-Provider Care

These 8 measures translate into 6 focus areas that CMS is currently working on reviewing and providers should pay close attention to. These quality priority areas include:
✓ Safer care when providing care
✓ More family involvement in patient care
✓ Better communication and coordination of care
✓ Prevention and treatment of chronic diseases
✓ Promote healthy living
✓ Affordability of care.

Hospice providers who have less than 30 quality surveys will not receive a rating. For hospices with less than 50 patients within a year, providers could ask for a waiver to be excluded from mandatory participant in the CAHPS hospice surveys. New agencies would still be exempted from the reporting requirements for 2 years under the proposed rule.

The proposed rule also solidifies the CAP annual period. The CAP period will start on October 1st each year and end on September 30th. This codification will appear in section 418.3.

With the recognition of physician assistants (PAs) as an attending physician for hospice purposes, one requirement has not changed. A physician must still certify the need for services. The proposed rule merely seeks to clarify the language in section 418.3 and section 418.304.

While these changes are largely positive, hospice providers should be able to feel better going forward. The proposed changes usually reflect the final rule for the upcoming year. Unlike other providers such as home health, hospice providers continually see reimbursement increases while undergoing regulatory reform. Hospices also tend to be more financially sound and profitable than their home health counterparts. This is all great news for hospices throughout the country. Continued success will be dependent on strong reporting through cost reports and hospice quality reporting mandates.

We will continue to keep you update throughout the summer as the new final rule for 2019 comes out. Comments for the proposed 2019 rule are due by the end of June (6/26/18). Providers are encouraged to submit comments on the proposed rule on an area or item they feel strongly works or doesn’t work. These comments do become part of the final outcome and often receive attention from CMS. Providers can report comments online by visiting regulations.gov and entering “hospice care” in the search bar. Then, select “Medicare Program: FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements”. – Hospice Today