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Volume 25.01

All hospices that were certified on or before October 1, 2023, are required to submit a Self-Determined Hospice CAP (“SDHC” or “CAP”) Report on or before February 28, 2025.  The CAP Report will generally cover claims for the period of October 1, 2023, through September 30, 2024.  Exceptions are as follows:

  • Hospices certified after October 1, 2023, will file their first CAP Report on or before February 28, 2026, This Report will cover claims for services from the date of certification through September 30, 2025.
  • Hospices certified on or after October 2, 2022, will submit their first CAP Report covering the period from Medicare certification through September 30, 2024, on or before February 28, 2025.

Instructions for the filing from each of the Medicare Administrative Contractors are available at:

Failure to submit the CAP Report by February 28, 2025, will result in a 100% payment suspension.

Although hospices are required to submit payment for any CAP liability at the time of filing, the current practice of the Medicare Administrative Contractors (“MACs”) is to allow providers to not submit payment at the date of the filing but rather to wait until such time as the MAC issues a demand for payment.  The respective MACs have unique protocols for when the repayment demand is made and whether the calculations as reported by the hospice are revised for more current data in the PS&R System.  Hospices should consult with their CAP advisor regarding whether to make payment at the time of filing or waiting until the repayment demand is issued.

If your CAP Report indicates a liability at the time of filing, do not submit a Request for Extended Repayment Schedule (“ERS’) at the time of filing.  This will cause significant confusion as there is no documentation available supporting the MAC’s determination of liability.  The Hospice should wait for the repayment demand to request an ERS.  However, if you are aware of the pending repayment demand, your hospice should begin assembling all the information to support your pending ERS request.

The MACs can recalculate CAP liabilities for prior CAP Years, and, in fact, it is not uncommon for the MAC to recalculate prior year CAP liabilities simultaneously with the review of the submitted CAP Report.

DON’T FORGET TO MONITOR THE CLAIM DENIAL IMPACT ON CAP LIABILITIES

As part of the significant focus on hospice payments, hospices find themselves subjected to a variety of audits including Targeted Probe and Education (“TPE”), Supplemental Medical Review Contractors (“SMRC”), Unified Program Integrity Contractors (“UPIC”), and Recovery Audit Contractors (“RAC”).  It is not unusual for hospices to be subjected to multiple audits at the same time.

If your hospice has incurred CAP liabilities in any year to which denials relate it is possible that you may be entitled to a refund of a portion of the CAP liability that was paid.  If this could apply to the hospice we recommend that your CAP advisor look into the refund potential on your behalf.  You may need to request any refund to which you are entitled.