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Finance:

Countdown To Hospice Cap Reporting For 2022 Approaches Final Hours

Published on Fri Feb 03, 2023

Avoid a payment suspension with timely filing.

If you haven’t done so yet, it’s time to hop on cap reporting.

Why it matters: “Any hospice that does not report its self-determined cap by [the deadline] will be subject to a 100 percent payment suspension,” warns HHH Medicare Administrative Contractor National Government Services on its website.

The Centers for Medicare & Medicaid Services has been requiring freestanding and hospital-based hospices to self-report their own aggregate caps, and submit any corresponding cap overpayments, since 2015. And CMS changed the cap reporting year to match the federal fiscal year in 2017 (see HHHW, Vol. XXVI, No. 24).

“Hospices are required to file a self-determined cap no earlier than 3 months, and no later than 5 months after the end of the hospice cap year, September 30,” HHH MAC CGS reviews on its Hospice Cap webpage. “The earliest a hospice may file its self-determined cap is December 31, and the latest is February 28 of each year,” the MAC says.

That date doesn’t always hold, actually. If the Feb. 28 deadline falls on a weekend or there’s a leap year, it shifts. For example, when both circumstances applied in 2020, the reports were due on Mon. March 2.

However, Feb. 28 is the deadline for this year. Each of the three HHH MACs has its own report submission instructions.

“Providers are required to obtain their own PS&R data in order to complete the self-determined hospice cap report,” HHH MAC Palmetto GBA reminds hospices in an article posted Jan. 24, “Provider Self-Determined Aggregate Cap Limitation Form Due February 28, 2023.”

“If you do not have access to CMS’ Identify Management System (formerly EIDM), through which the PS&R data is available, it is advisable that you take action immediately to ensure timely access so that you can meet the reporting deadline,” advises the National Association for Home Care & Hospice in its member newsletter.

How it works: The “cap is calculated by multiplying the statutory cap amount by the number of beneficiaries in the cap period and comparing this to payments received,” NGS explains. For 2022, the cap amount was $31,297.61.

Don’t overlook: “Please note physician services are not excluded from the net reimbursement,” NGS points out.

Know Your Beneficiary-Counting Method

For the cap calculation, “the number of beneficiaries is determined by either the proportional method or the streamlined method. For either method, the PS&R system provides reports of the data in the Miscellaneous Reports section to identify the beneficiary counts.”

Background: Back in 2012, sparked by numerous lawsuits, CMS switched hospices from the old streamlined method of counting benes to the proportional method. Under the proportional method, a beneficiary counts in the calculation year based on time. For example, a beneficiary on service for nine months in 2021 and three months in 2022 would count as a 0.75 patient in the former and 0.25 patient in the latter year’s calculation.

At that time, hospices could elect to stick with the streamlined methodology for bene-counting if they wished (see Eli’s HCW, Vol. XX, No. 37). But they are not allowed to switch back and forth. Once they choose to use the proportional method, they must stay with it. “The streamlined method is only available to hospices that previously elected this method before 2012,” NGS clarifies.

Watch out: Under the proportional method, hospices can expect their cap-related overpayments to grow from the figure initially determined in their report. “As a patient continues on hospice care, the proportional beneficiary count will tend to decrease with the increase in the total days of hospice care,” Palmetto explains. “As a result, the overpayment may increase from the amount self-determined.” The MAC will assess updated overpayments based on shifting beneficiary counts as time goes on.

The calculations vary a bit for newly certified hospices that enter the Medicare program and do not participate for an entire cap year. In that case, “the initial cap calculations for newly certified hospices must cover a period of at least 12 but less than 24 months,” CGS explains. “For example, the first cap period for a hospice that entered the program on September 1, 2021, is from September 1, 2021 through September 30, 2022.”

Then, hospices must “order your PS&R Summary and Hospice Cap reports from the agency’s tie-in date to September 30 of the second cap year. (i.e., September 1, 2021 – September 30, 2022). To obtain the correct beneficiary count from the Hospice Cap report, add the count from the 2021 and 2022 cap years,” CGS instructs. “You will also need to calculate a prorated Hospice cap amount,” the MAC adds.

And don’t get confused about where to send your cap report. “If CGS does not pay your agency’s Medicare claims, we are not responsible for the Hospice Cap work for your agency,” the MAC stresses in a new message to providers. “Submit your SD Cap and direct any questions to the MAC that pays your claims,” CGS instructs.

If your cash flow isn’t up to the task of repaying your cap overage, you do have options. “If a provider is unable to repay the self-determined overpayment within 15 days,” NGS notes, “they can submit a request for an ERS” — an Extended Repayment Schedule, commonly called an Extended Repayment Plan. If approved, “please note interest starts after 30 days,” the MAC adds.

Unless you can survive for some time on no cash, be sure to keep up with the deadline. “If the form is not received timely, a past due letter will be issued and payments will be suspended,” Palmetto warns on its webpage. And it could take a while to get those payments restored, even if you act quickly on your side. “File soon so payments will not be suspended,” the MAC urges.

Note: Find MAC aggregate hospice cap information at https://cgsmedicare.com/hhh/audit/hos_caps.html for CGS; www.ngsmedicare.com/web/ngs/cost-reports?selectedA rticleId=1037138 for NGS; and https://palmettogba.com/ palmetto/jmhhh.nsf/DIDC/BK5R4Z8172~Audit and Reimbursement~Provider Statistical and Reimbursement for Palmetto.

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