Pre-Payment Review Results for High-Risk Hospices in Ariz., Calif., Nev., Texas for January to March 2025

Published 04/22/2025

Pre-Payment Review Results for High-Risk Hospices on New Hospices in Arizona, California, Nevada and Texas for January through March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the Probe and Educate process for High-Risk Hospices in Arizona, California, Nevada and Texas. The reviews with edit effectiveness are presented here for Jurisdiction M.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed Providers Non-Compliant Progressing to Subsequent Probe
33 16 17
Table 2. Cumulative Results.
Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
330 99 30% $1,150,471.39 $455,847.02 40%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe
Texas 24 8 16
Table 4. Probe One Findings.
State Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 240 92 38% $920,461.26 $437,439.23 48%

Probe Two Findings

Table 5. Probe Two Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe
Texas 9 8 1
Table 6. Probe Two Findings.
State Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 90 7 8% $230,010.13 $18,407.79 8%

Risk Category

The categories for High-Risk Hospices in Arizona, California, Nevada and Texas are defined as:

Table 7. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for High-Risk Hospices in Ariz., Calif., Nev. and Texas.

Pie chart showing 52% Minor and 48% Major.

Top Denial Reasons Probe 1 and Probe 2

Table 8. Top Denial Reasons Probe 1 and Probe 2.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
25% 5FF36, 5CF36 Documentation Submitted Does Not Support Prognosis of Six Months or Less 20
14% 5FFNP, 5CFNP No Plan of Care 11
11% 5FFH9, 5CFH9 Physician Narrative Statement Not Present or Not Valid 9
10% 5FNER, 5CNER The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements 8
9% 5FFH3, 5CFH3 No Certification for Dates Billed 7

Denial Reasons and Recommendations

5FF36/5CF36 — Documentation Submitted Does Not Support Prognosis of Six Months or Less 

Reason for Denial 
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less.

How to Avoid This Denial

  • Ensure a legible signature is present on all documentation necessary to support a six-month prognosis 
  • Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognoses which supports hospice appropriateness at the time the benefit is elected and continues to be hospice appropriate for the dates of service billed
  • Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses 
  • Submit documentation which supports the coverage criteria outlined in the policy. LCDs may be viewed on the Palmetto GBA website
  • If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight and any related interventions
  • Document any comorbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

References

5FFNP/5CFNP — No Plan of Care

Reason for Denial
The claim has been fully or partially denied as documentation submitted for review did not include a plan of care (POC) for all or some of the dates billed. Claims with dates of service beginning July 19, 2010, require that a valid POC be included as part of the medical review process according to Change Request 6982.

How to Avoid This Denial

  • The hospice must submit a POC for dates of service billed when responding to ADR request
  • All dates billed must be covered by a POC to be payable under the Medicare hospice benefit
  • If more than one POC covers the dates of service in question, submit all the related POC for review
  • The POC must contain certain information to be considered valid. This includes: 
    • Scope and frequency of services to meet the beneficiary’s/family’s needs
    • Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
    • Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions
  • The POC must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment
  • All hospice care and services must follow an individualized written POC
  • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC

References

5FFH9/5CFH9 — Physician Narrative Statement Not Present or Not Valid

Reason for Denial 
The claim has been denied as the physician narrative statement is not present or not valid.

How to Avoid This Denial 

  • The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
  • If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature
  • If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum
  • The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he or she composed the narrative based on his/her review of the patient’s medical record or, if applicable his or her examination of the patient
  • The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients

References

5FNER/5CNER — The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements

Reason for Denial
The claim has been fully or partially denied as the documentation submitted indicates that the statutory/regulatory requirements for the Hospice Election Statement were not met. 

How to Avoid This Denial
A Medicare beneficiary must complete an election statement before the Hospice Medicare Benefit can begin. The election statement must include the following items of information:

  • Identification of the particular hospice that will provide care to the individual
  • The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
  • The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
  • The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive
  • The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or Nurse Practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician
  • The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice
  • For hospice elections beginning on or after October 1, 2020, the hospice must provide:
    • Information on individual cost-sharing for hospice services
    • Notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice
    • Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information
  • The signature of the individual or representative

References

5FFH3/5CFH3 — No Certification for Dates Billed 

Reason for Denial
The claim has been fully or partially denied as documentation submitted for review did not include a certification covering all or some of the dates billed.

How to Avoid This Denial

  • The hospice must obtain written certification of terminal illness for each benefit period
  • All dates billed must be covered by a certification to be payable under the Medicare hospice benefit
  • If more than one certification covers the dates of service in question, submit all the related certifications for review

References

Education
Palmetto GBA offers providers selected for review an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for review to request education. If education is desired, please complete the Education Request Form (PDF). 

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of HRH Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of HRH Probe 2 may potentially advance to a subsequent Probe for TPE after at least 35 days from issuance of results letter.


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