How to Avoid the Top 4 Reasons for Hospice Claims Denials

Hospice Claims Denials

As the Centers for Medicare & Medicaid Services (CMS) continues its crackdown on hospice billing, you can expect increasing denials and ever-harsher scrutiny of your claims. And this is why, now more than ever before, you need to stay current on the most prevalent hospice denials and how to avoid common billing pitfalls.

On Jan. 1, 2018, CMS updated the hospice billing guidelines, and plenty of confusion remains surrounding submission of the hospice Notice of Election and Certificate of Terminal Illness, according to home health and hospice expert Judy Adams in her audioconference, “Avoid Hospice Bill Mistakes and Denials.” The latest CMS changes will no doubt only complicate your hospice billing practices and further put you at risk for claims denials.

Beware of the Most Widespread Billing Mistakes

If you want to avoid hospice denials (and who doesn’t?), first you need to know the most common denial reasons. The top four are:

  1. Documentation doesn’t support a terminal prognosis: Overwhelmingly, this is the top reason for denial of a hospice claim. CGS Administrators, LLC reported that, from January through March 2018, a whopping 81 percent of denied claims had a denial code of 5PM01 — which indicates, according to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less.
  2.  Unmet FTF Encounter requirements: Another common reason for hospice denials stem from Hospice Face-to-Face (FTF) Encounter requirements.
  3.  Noncompliant Plan of Care: You may also see denials because your hospice care plan doesn’t meet the Medicare requirements set out in the Code of Federal Regulations, Title 42, Part 418.
  4.  Missing (or late) MR ADR documentation: When you submit a claim for medical review and the payer generates a medical review additional development request (MR ADR), you must provide the requested documentation, and in a timely manner—or risk denial.

Heed Expert Tips to Prevent Denials

When you’re dealing with denials due to missing certification of a terminal illness or an invalid physician certification due to FTF Encounter issues, take immediate action.

Do this: Make sure you track all certifications/recertifications and FTF documentation to ensure these elements are present in the medical record, advised Karla Lykken, RN of Kindred at Home in a presentation for the Texas & New Mexico Hospice Organization.

Also, audit your certifications/recerts and FTF documents to ensure they’re complete, as well as signed and dated in a timely manner, Lykken said. And gather the following necessary documents:

  • Plan of Care
  • Establishment of the Plan of Care
  • Orders and medication profiles
  • Initial/Admission Comprehensive Assessments
  • Hospice Aide and Volunteer Assignments (first and most current assignments)
  • Interdisciplinary Group (IDG) Review and updates to the Plan of Care (all that apply to the dates under review)
  • Election of Benefits/Consents
  • All visit notes by all disciplines (including hospice aide and volunteer notes)
  • Additional documents that may support eligibility (e.g., labs, antibiotics orders, medication changes, etc.)

Keep Your Documentation Tidy

Finally, failing to submit requested documentation is probably the easiest denial reason to address, Lykken noted. Even if you feel like you might not get paid by Medicare or Medicaid, you must always respond to documentation requests, because failure to respond will likely place even greater scrutiny on you as a provider.

Do this: Respond to all Medicare/Medicaid requests for medical records, Lykken stressed. Carefully read each documentation request and note the due dates, as well as any specific necessary documents.

Best bet: Your records “should be so well-organized that your elementary school librarian would be proud,” quipped Jason Bring of Arnall Golden Gregory LLP in his Annual Hospice & Palliative Care Conference presentation on Zone Program Integrity Contractor (ZPIC) audits. Remember that payers and auditors are looking for reasons to deny your claims, so make it difficult for them to do so.

Key takeaway: If you want timely and accurate reimbursement, you must run a tight billing ship. Learn from Adams how to conduct pre-bill audits and documentation best practices to prevent denials—and submit clean, irrefutable hospice claims every time.

To join the conference or see a replay, order a DVD or transcript, or read more

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