UPIC Hospice Cap Liability Process – Coordination with the

4.7.6 – UPIC Hospice Cap Liability Process – Coordination with the MAC (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) This section applies to UPICs. Medicare Part A includes a hospice benefit for terminally ill patients. Congress has established a retrospective “cap” on the aggregate amount that Medicare will reimburse hospice providers each year. Historically, PI contractor reviews of hospices have overlapped with the MAC review of the benefit cap liability for those same hospices; resulting in a potential double recovery for the government. Therefore, the following communication and process between the UPICs and MACs shall be followed, in order to minimize the occurrence of these double recoveries, and check the RAC Data Warehouse to ensure the provider is not under suppression. • UPIC Initiated Reviews: o When selecting claims using statistical sampling that may result in an actual and/or extrapolated overpayment, upon the initiation of a hospice review, the UPIC shall coordinate with the MAC to determine whether the hospice is subject to any finalized or ongoing cap liability reviews (self- reported, final, and/or re-opening) for the applicable period of the UPIC’s audit. If there are no cap liability determinations, the UPIC shall proceed with its review. Upon identification of an overpayment, the UPIC shall coordinate with the MAC to ascertain whether in the intervening period (from the claims selection period to the overpayment determination) the hospice had become subject to any cap liability proceedings for that same period. The UPIC shall finalize its review and issue the findings to the hospice and refer any overpayment to the MAC for collection. The MAC shall take into account the cap liability and adjust as appropriate. If it is determined that the hospice is subject to any finalized or ongoing cap liability reviews (self-reported, final, and/or re-opening), the UPIC shall consult with the MAC and design a statistical sampling for overpayment estimation (SSOE) for those specific year(s) according to the cap determinations to assist with reconciling cap overpayments. The UPIC shall finalize its review and issue the findings to the hospice and refer any overpayment to the MAC. The MAC shall take into account the overpayments submitted by the UPIC and apply these to any subsequent, ongoing cap overpayments (self-reported, final, and/or reopening). This process ensures that a provider is not penalized for the same beneficiary twice.