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HCA Submits Comments on FY 2019 Hospice Proposed Rule

Yesterday, HCA submitted extensive written comments on the Fiscal Year (FY) 2019 proposed rule for Medicare hospice payment updates, wage index changes and quality reporting. The proposed rule was posted in April by the U.S. Centers for Medicare and Medicaid Services (CMS) and previously summarized to the HCA membership in our newsletter.

Our comments can be downloaded here.


On the payment side, our comments specifically address several items in the proposed rule, including:

  • Continuation of the two-tier routine home care (RHC) payment rate and CMS’s plans to monitor long length-of-stay patients. HCA requested a data analysis from CMS on the new payment system to better assess its impact.
  • Our recommendation that Licensed Practical Nurses (LPNs) be included as part of the service intensity add-on payment.
  • Concerns about the wage index calculations, which are especially problematic for hospice providers in New York City, given the inclusion of non-New York counties in the regional designation and other refinements that are needed. HCA again called for revisions in this area.

Non-Hospice Spending and Cost Reports

HCA also reacted to CMS’s concerns about the prevalence of non-hospice spending within a beneficiary’s hospice benefit, as well as CMS’s analysis of the revised hospice Medicare cost report.

Regarding non-hospice spending, HCA expressed encouragement that hospices and vendors will take advantage of the new electronic submission option for the hospice Notice of Election (NOE) which could enhance the availability of patient status updates in the CMS systems, mitigating concerns about this issue.

In its analysis of hospice cost reports, CMS anticipates that 66 percent of hospices would have their cost report rejected if Level 1 edits were implemented based on recommendations from the Home Health and Hospice Financial Managers Association. Since accurate cost reports are critical (CMS uses them for rebasing and other purposes), HCA urged CMS to work with all hospice stakeholders to make education sessions and webinars widely available so that all hospices have a clear understanding of any such revisions and/or Level 1 edits well before they are put into place.


HCA also commented on four different areas within the Hospice Quality Reporting Program (HQRP) including: 1) our support for a new measure-removal factor when costs associated with a measure outweigh the benefit of its continued use in the program; 2) procedures to determine the readiness of quality measures prior to public reporting; 3) concerns about the display of the public use data file data on the Hospice Compare website; and 4) the impact of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which is another unfunded mandate in need of reimbursement.


CMS’s proposed rule also asked for input on areas that could use some regulatory flexibility and/or efficiencies. HCA appreciated the opportunity to offer the following recommendations that we believe would help reduce the regulatory burden on hospice providers. Two such areas are summarized below.

  • Revise the Face-to-Face (F2F) Regulatory Requirement for Hospices

The intent of F2F was to ensure adequate and appropriate involvement and accountability of physicians relative to certification of eligibility for hospice care. However, as currently written and interpreted by CMS, this rule poses a delay in access to care and serves as a deterrent for some hospices to take eligible patients in need of immediate care onto service.

HCA urges CMS to work with the hospice industry to significantly revise the F2F provision so that regulations and guidance governing F2F provide sufficient flexibility, allowing hospice programs to comply without any threat of delayed access to care for beneficiaries in need of hospice services, and without undue financial burdens. (HCA has similarly sought these revisions at many levels for both home care and hospice providers in the past.)

  • Amend Sequential Billing Requirements for Hospices that Cause Payment Delays and Increase Regulatory Burdens

CMS’s sequential billing policy prohibits hospice providers from submitting claims for care to beneficiaries where previously submitted claims are pending. However, claims processing can be delayed for weeks or months for many reasons, including medical review activities, common working file (CWF) problems, CMS or Medicare Administrative Contractor (MAC) claims-processing problems and pending claims from other providers, etc.

HCA recommends that CMS still require hospices to submit claims in chronological order but process and pay all clean claims as submitted, regardless of whether previous claims have been processed. CMS should also allow more than one claim per beneficiary per month when the reason for the multiple claims is due to the hospice exceeding the 450-line claim limit. CMS should also pay interest on claims that are not processed timely.


In our comments, we also took the opportunity to strongly encourage CMS to begin offering Health Information Technology (HIT) capital funding and/or grants so that more hospices and home health agencies can begin advancing the interoperable exchange of critical health information to their critical health care partners.

For further information, contact Patrick Conole at (518) 810-0661 or