Eli's Hospice Insider

Published on Fri Aug 16, 2013 PDF

Denial reasons differ for first versus later hospice benefit periods.

Make sure your certifications and terminal illness documentation are up to snuff for hospice claims, or you may lose your rightful reimbursement.

In a recent review, HHH Medicare Administrative Contractor NHIC conducted probes of hospice claims in their first, second, and third benefit periods. Reviewers denied 31 percent of claims for the first and second period, and 27 percent of claims in the third period.

Results: Lack of valid physician certification was the top denial reason (43 percent) for first-period claims, timely physician cert/recert was second (20 percent), and terminal prognosis was third (19 percent). In second and third periods, terminal prognosis moved to the top denial reason spot (41 and 50 percent, respectively). Lack of valid physician certification moved to the second spot (31 and 33 percent, respectively). Untimely physician cert/recert dropped sharply to 3 and 8 percent, respectively.

For terminal prognosis denials, “the documentation demonstrated the patients were custodial care patients, and did not support the patient had a terminal prognosis of less than six months to live if the disease or condition ran its normal course,” NHIC explains.

You may need to submit more documentation than you think to support terminal prognosis in later episodes, the MAC suggests. “This may require sending in the initial start of care (SOC) documentation, the documentation for the month requested and any documentation between the SOC and month reviewed that helps support terminal prognosis,” the MAC says in an article at www.medicarenhic.com/providers/articles/RHHIProbe061313.pdf