(a) HHSC recoups from a hospice under 40 TAC §49.533
(relating to Recoupment) amounts paid to the hospice for a service
if the hospice has not complied with the requirements described in
this chapter.
(b) Recoupment amounts for hospice eligibility and
level of service utilization reviews.
(1) HHSC recoups 100 percent of the hospice claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC the following:
(A) the Individual Election/Cancellation/Update Form
completed in accordance with §266.205 of this subchapter (relating
to Election of Hospice Care);
(B) the Physician Certification of Terminal Illness
Form completed in accordance with §266.203 of this subchapter
(relating to Certification of Terminal Illness);
(C) a physician narrative that meets the minimum criteria
in §266.203(c)(2) of this subchapter; or
(D) if the individual receiving hospice services is
in an election period after the subsequent 90-day election period,
documentation of the face-to-face assessment required by §266.203(d)
of this subchapter.
(2) HHSC recoups 50 percent of the hospice claim amount
for the dates of service reviewed when the hospice fails to provide
nursing assessments and notes.
(3) HHSC recoups 30 percent of the hospice claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC supporting clinical documentation related to the terminal illness
and the progression of the terminal illness, including signs and symptoms,
anthropometric measurements, weights, oral intake, and laboratory
and diagnostic testing.
(4) HHSC recoups 25 percent of the hospice claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC with documentation of an initial plan of care and updated plans
of care as required by §266.211 of this subchapter (relating
to Continuous Home Care) and §266.221 of this subchapter (relating
to Hospice Documentation Requirements).
(c) Recoupment amounts for CHC reviews.
(1) HHSC recoups 100 percent of the CHC claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC the following:
(A) documentation establishing that a crisis existed;
(B) a physician's order for CHC; or
(C) documentation establishing that the individual
received care for at least 8 hours within a 24-hour day during the
period of crisis.
(2) HHSC recoups 50 percent of the CHC claim for the
dates of service reviewed when the hospice fails to provide HHSC documentation
establishing that the hospice agency employees provided skilled nursing
care for more than 50 percent of the period of crisis.
(3) HHSC recoups 25 percent of the CHC claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC the following as required by §266.211 of this subchapter
and §266.221 of this subchapter:
(A) the plan of care specific to the identified crisis
and dated before the initiation of CHC;
(B) documentation that is legible to a reader other
than the author, clear, complete, signed or initialed, and dated in
accordance with hospice policy and currently accepted standards of
practice; or
(C) documentation that is signed and appropriately
authenticated, which means the hospice is able to authenticate each
handwritten and electronic signature of a primary author who has reviewed
and approved the entry.
(4) HHSC recoups 10 percent of the CHC claim amount
for the dates of service reviewed when the hospice fails to provide
HHSC documentation of the discussion of temporary alternate placement
required by §266.211(6) of this subchapter, including documentation
of the IDT meeting and who participated in the IDT meeting.
(d) Other. HHSC will recoup the amount of any overpayment
discovered.
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