SECTION 266.223. Recoupment

(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.

Source Note: The provisions of this §266.223 adopted to be effective July 26, 2022, 47 TexReg 4331