Palmetto GBA announce their intent to focus on certain hospice claims for patients located in Skilled Nursing Facilities (“SNFs”)

On October 29, Palmetto GBA announced their intent to focus on certain hospice claims for patients located in Skilled Nursing Facilities (“SNFs”).  Palmetto GBA announced that it has identified top providers with a large number of beneficiaries receiving hospice services in SNFs, and it intends to initiate a pre-payment, service-specific investigation of claims for beneficiaries with non-cancer diagnoses.  While the claims timeframe is unknown, the investigation will be initiated in Jurisdiction 11, which covers home health and hospice services in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, Tennessee and Texas.  Once complete, review results will be posted on the Palmetto GBA website and individual providers may be contacted for one-on-one education.

SNF’s may want to review their residents receiving hospice services to identify those with non-cancer diagnoses and ensure the medical records contain sufficient documentation to demonstrate the illness is terminal and progressing in a manner that a physician would reasonably have concluded that the beneficiary’s life expectancy is six months or less. Documentation is especially important for residents that remain on the hospice benefit for an extended length of time in order to demonstrate why hospice services are appropriate.

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to Palmetto.  When the claim is finalized, the claim will have paid in full or part, or denied. If you disagree with the decision, you may request a redetermination within 120 days of the determination (date on the remittance advice). Completed review results will be posted to the Palmetto GBA website.

A SNF’s corporate compliance officer may want to designate a team to evaluate whether or not this hospice issue applies to them and if so, designate resources to proactively assess the situation.  Please contact any Krieg DeVault health care attorney to assist you with any questions you might have.

A copy of the notice can be found here.

For questions, please contact Lori McLaughlin