New transfer and discharge billing procedure for hospice

The Centers for Medicare and Medicaid Services (CMS) is issuing a new billing requirement to close the gap on hospice care and billing when a hospice patient transfers from one provider to another.

New requirements taking effect July 1, 2022, will require the patient to re-elect hospice care with the new hospice when the

“from” date of service for the receiving hospice is not the same as the “through” date of service for the transferring hospice.

“This means any billing gap, even it’s only one day, will be considered a discharge and readmission rather than a transfer,” said SimiTree Principal Jess Stover who oversees SimiTree’s billing, collections, and revenue cycle management outsourcing services.

“CMS will reject the hospice transfer if those dates don’t match, and a new notice of election (NOE) will be required with the new provider,” Stover said.

Currently, there is no mechanism in place to prevent gap billing. Transfers are allowed to process through Medicare’s Common Working File (CWF) whether or not the “from” date for the receiving hospice provider matches the “to” date for the transferring hospice provider.

“But CMS has said that there cannot be a gap in the number of billing days between the transferring and receiving hospice,” Stover said.

“So, it is creating a new edit to the Common Working File that will no longer allow these gaps. If the receiving hospice’s claim ‘from’ date is not the same as the transferring hospice provider’s ‘through’ date and the ‘patient status’ does not indicate a transfer with codes 50 or 51, the transfer will be rejected.”

CMS announced the gap billing change for hospice in February. It will become effective on July 1, 2022.

Compliance Tips

Stover offered a few compliance tips for the new hospice requirement:

A hospice patient may change hospices only once per benefit period (60-day or 90-day).
When the patient transfers to a different hospice, he or she continues in the same benefit period.
To transfer hospice programs, the individual or patent representative must file a statement with both the hospice from which care has been given and with the newly designated hospice. The statement must include:
1. The name of the hospice from which the individual was given care and the name of the hospice from which he or she plans to get care
2. The date the change is to be effective.
The new gap billing change will not apply to transfers to and from the same provider, when the patient is being transferred to another location of the same hospice and the CMS Certification Number (CNN) is the same.
If the hospice patient enters another hospice after any break in care, CMS considers the patient to have been discharged. Discharge will trigger the start of a new election period. A new NOE will be required.
If the patient is transferring from outside the service area and the transferring hospice cannot arrange care until the patient reaches the new hospice, the hospice may discharge the patient.
Any discharge without an immediate transfer also triggers restart of Medicare benefits waived under 42 CFR 418.24(d). The regulations at 42 CFR 418.26(a)(1) state that an individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice, is no longer covered under Medicare for hospice care. However, regulations also state that regular Medicare coverage resumes.

“This way, if the patient requires medical treatment while in the process of transferring, he or she can access it under original Medicare coverage,” Stover said.

Need help with billing?

As Medicare intensifies billing requirements for both home health and hospice, SimiTree knows it can be challenging for your agency to stay abreast of the changes.

We’ll provide all the training needed for full compliance, or we’ll handle the work for you with our full array of outsourced billing, collections, cash posting and revenue cycle management services.

With newly expanded resources, we’re ready to deploy immediately, becoming a friendly extension of your own team.

“Our newly expanded resources enable us to work with agencies of all sizes, from start up to enterprise,” Stover said. “We offer full outsourcing solutions as well as consulting services to help with cash flow, compliance, claims processing delays, and profitability.”

Reach out to learn how SimiTree can help your agency, and get a free quote on our outsourced billing, coding, and full revenue cycle management services. Use the form below to let us know how we can help.