NPHI met with CMS Administrator Seema Verma in mid September about the issues related to ongoing audits that are leading to claims being routinely denied based on an overly simplified conclusion that the documentation fails to show continuous “terminal decline”, as clinically defined by the MAC, ZPIC, and other contract reviewers rather than as clinically defined by and certified by the clinical judgment of the certifying physicians. These “rule of thumb” denials related to “terminal decline” are not aligned with the hospice statute nor with Medicare’s corresponding regulations. We requested that CMS assign a point person to work with us on guidance to its contractors that clarifies that payment denials strictly based a “terminal decline” requirement is not in accordance with the law and must cease. 

 

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