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The Fundamentals of Hospice Compliance What Is It and What Are the Implications for the Future? An Overview for Hospice Clinicians Part 2: Hospice Risk Areas

doi: 10.1097/NHH.0b013e318257d68a
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The Fundamentals of Hospice Compliance—What Is It and What Are the Implications for the Future? An Overview for Hospice Clinicians, Part 2: Hospice Risk Areas


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GENERAL PURPOSE: To continue the examination of the Medicare compliance climate and its impact on hospice providers, with a focus on hospice-specific compliance risk areas and specific risk-reduction strategies.

LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to:

  • Summarize the background information essential for understanding hospice compliance risk areas.
  • Apply the regulations presented here to hospice practices.
  • Give examples of recommendations for assessing a hospice's compliance performance.
  1. To be eligible for the Hospice Medicare Benefit (HMB), a beneficiary must be certified as having a terminal prognosis with a life expectancy of
    1. 3 months or less.
    2. 6 months or less.
    3. 9 months or less.
    4. 12 months or less.
  2. If the hospice determines that the beneficiary no longer meets the requirement for the HMB, it must
    1. recertify the patient.
    2. appeal the requirement.
    3. arrange alternative care.
    4. initiate discharge.
  3. By 2010, what percentage of individuals admitted to hospice care had a primary diagnosis of cancer?
    1. 35.6%
    2. 44.3%
    3. 56.1%
    4. 63.8%
  4. The sole source of data to support eligibility and coverage is the
    1. hospice patient's signed consent form.
    2. admitting physician's prescription for care.
    3. family's request for palliative care.
    4. hospice patient's clinical records.
  5. 5. Of the following, which is an HMB level of care that is reimbursed at the highest level?
    1. routine home care
    2. continuous care
    3. symptom management
    4. general inpatient care
  6. Which of the following is an essential question for assessing performance in the areas of general inpatient care and continuous care?
    1. Does the staff know the signs and symptoms of advancing disease progression?
    2. Is the ability to explain the HMB treated as a staff competency and tested periodically?
    3. Would clinical record reviews consistently demonstrate what precipitated the patient's need for the higher level of care?
    4. Is documentation of individual team members monitored, particularly soon after hire?
  7. The HMB uses a prospective pay model, which means that providers
    1. are paid a fixed amount based on the level care.
    2. receive additional reimbursement for costly medications.
    3. are paid the costs they project for the upcoming month.
    4. receive reimbursement for the actual cost of required services.
  8. Which of the following is an essential question for assessing performance in the area of revocation of care?
    1. Does the clinical staff understand the difference between a denial and a revocation?
    2. Does the patient understand that the hospice can initiate the revocation?
    3. How frequently are revocations closely followed by a reelection?
    4. What interventions were put in place to try to avoid revocation?
  9. 9. A recent review of 450 randomly selected claims of hospice patients who resided in nursing homes found that what percentage did not meet at least one Medicare coverage requirement?
    1. 55%
    2. 67%
    3. °74%
    4. °82%
  10. Which of the following is an essential question for assessing performance in the area of elections?
    1. Is the ability to explain the HMB treated as a staff competency and tested periodically?
    2. Does the clinical record paint a clear picture of the reason for the election?
    3. How was the professional management of the election accomplished?
    4. Are all disciplines supporting and capturing decline and disease progression?
  11. Which of the following is an essential question for assessing performance in the area of certification?
    1. Is the process clearly written out in priority order?
    2. Is the certification form signed by the beneficiary or the beneficiary's representative?
    3. Do people understand that they can make some types of changes to the process on their own?
    4. Do at least two people know the process accurately or operationally from start to finish?
  12. Hospices' requirements for care planning spell out content, intervals for review and update, and
    1. internal pricing policies.
    2. coordination of services.
    3. lines of communication.
    4. compliance concerns.
  13. Which of the following is specifically recommended for assessing performance in the area of hospice care in nursing homes?
    1. using the material in the Interpretive Guidelines
    2. overseeing revisions in plans of care
    3. reviewing the 1998 Fraud Alert
    4. developing corrective actions
  14. A specific recommendation for developing regulatory competency is to establish defined expectations of regulatory knowledge by
    1. function.
    2. objectives.
    3. resources.
    4. position.
  15. Another specific recommendation for developing regulatory competency is to institute an ongoing program of
    1. internal development.
    2. external communication.
    3. compliance reorientation.
    4. optimal reimbursement.


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