Hospice
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Although hospice care originated as a covered service through the Medicare program, the majority of states have elected to offer and fund a concurrent Medicaid hospice program for their covered populations. Although added as an optional Medicaid benefit to states in 1993, Section 2302 of the Affordable Care Act (ACA) mandates that states provide hospice care for children from birth through age 20. The hospice benefit includes an array of services furnished to terminally ill individuals to provide supports such as nursing, medical social services, physician services, counseling services to the terminally ill individual and the family members or others caring for the individual at home, physical therapy, occupational therapy, and speech-language pathology services.

Myers and Stauffer has extensive experience supporting state agency implementation of a companion Medicaid hospice benefit. Our team of clinical experts and accountants assist state Medicaid agencies in determining whether provided services are medically necessary, performing documentation verification that services were actually provided, and evaluating whether Medicaid claims were properly submitted and adjudicated. We also assist state agencies annually with updating their hospice Medicaid reimbursement rates for routine home care, continuous home care, inpatient respite, and general inpatient care by utilizing data published in the Federal Register.

Audit and Attest

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Bob Hicks, CPA
member
bhicks@mslc.com

816.945.5321

We have assisted states in establishing inpatient hospice rates through their nursing facility rate setting systems. Many times these are established as a percentage or component of the full nursing facility reimbursement rate. Audit services for hospice include:

  • Utilize allowable costs in establishing reimbursement rates.
  • Identify allowable costs in accordance with state and federal definitions.

Rate Setting and Reimbursement

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Amy Perry, CPA
member
aperry@mslc.com

816.945.5342

Our team works from the premise that rate setting must be accurate, transparent, and predictable, while simultaneously demonstrating that payments are sufficient to support the delivery of high quality, cost-effective services and promote good health outcomes. As a public accounting firm, we have intimate knowledge of required principles that must be followed in the setting of rates and auditing of payment systems, and we are able to effectively apply that knowledge to Medicaid policy and program objectives in a manner that is highly efficient and that makes the best use of limited public funds.

  • Use published data to establish reimbursement rates.
  • Rate setting.
  • Utilization review.

Benefit/Program Integrity

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Ryan Farrell, CFE
Principal
rfarrell@mslc.com

512.342.0800

Many state agencies offer a hospice benefit, which offers end-of-life care for those beneficiaries with a terminal illness where, based on a physician’s clinical judgement, there is a life expectancy of six months or less if the illness runs its normal course. Through our benefit/program integrity services, Myers and Stauffer assists our government health care clients with performing compliance reviews of hospice patients to ensure eligibility for benefits. Focused reviews based on extended hospice stays, live discharges, and transfers between hospices can aide in the identification of troublesome providers. We also review other issues, including recruiting of hospice patients, higher use levels of hospice care (inpatient) than needed to meet the beneficiary’s end of life needs, adequacy of documentation, services in excess of policy limits, evidence of timely reassessments, face-to-face physician contact (when and where applicable), and qualifications of care givers.

  • Claims analysis.
  • Post pay claims audits – clinical/financial.
  • Pre pay claims audits – clinical/financial.
  • Medicaid RAC services.
  • SURS/FADS/case tracking modules.
  • Provider compliance.
  • Payment system processing accuracy.
  • Fraud, waste, and abuse detection (FWAD) litigation support.

Managed Care Oversight and Compliance

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Mike Johnson, CPA, CFE
Member
mjohnson@mslc.com
404.524.0775

The extensive services offered by our highly skilled managed care team are generally focused on the health plans but can impact all provider types, including hospice providers. These services include:

  • Network adequacy and member access compliance.
  • Claims payment and denial assessments, accuracy, and timeliness.
  • Grievance and appeals analysis.
  • Prior authorization reviews.
  • Program effectiveness audits.
  • Health plan contract compliance.
  • Other provider specific issue review and resolution activities.