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March 5, 2015

Sequestration — Impact on Hospice Aggregate Cap Calculations

On March 1, 2013, a sequestration order was issued, as required by law. The information below provides details on how the sequestration amounts shall be handled pertaining to the hospice cap calculation.

CGS will calculate the aggregate cap determination as follows:

The sequestration amount reported on the Provider Statistical and Reimbursement (PS&R) report for each hospice shall be added to the net reimbursement amount reported on the PS&R;
The resulting amount shall be compared to the hospice's aggregate cap amount to
calculate a pre-sequester overpayment; and
The pre-sequester overpayment shall be reduced by 2% to reflect the actual amount paid to the hospice. The 2% overpayment reduction cannot be greater than the actual sequestration amount reported on the PS&R report.

Please refer to the end of this article for a sample calculation of a hospice aggregate cap calculation.

The sequestration amount reported on the PS&R report for the 2013 cap year was accumulated for services on or after 04/01/2013. There is no need to split the PS&R report for periods 11/01/2012 – 03/31/2013 and 04/01/2013 – 10/31/2013.

CGS will perform the following steps if a 2013 hospice cap determination has been issued and the hospice was below the hospice aggregate cap:

Determine if the hospice exceeds the aggregate cap when the sequestration amount is added to the net reimbursement.
If the hospice exceeds the aggregate cap, the CGS will:
1. Issue a Notice of Reopening to revise the hospice cap determination to reflect the sequestration amount;
2. Recalculate the hospice cap determination in accordance with the above and issue a revised hospice cap determination; and
3. Issue a demand for the overpayment.

CGS will perform the following steps if a 2013 hospice cap determination has been issued and the hospice was above the hospice aggregate cap:

Issue a Notice of Reopening to revise the hospice cap determination to reflect the sequestration amount;
Recalculate the hospice cap determination in accordance with the above and issue a revised hospice cap determination; and
Issue a demand for the corrected overpayment.

CGS will determine if a reopening of a 2013 hospice cap determination is necessary and shall issue a Notice of Reopening within 150 days from March 3, 2015.

PROVIDER NAME:	Sample Hospice
PROVIDER NUMBER:	99-1500
NPI NUMBER:	123456789
CAP YEAR ENDING:	10/31/2013

Net Reimbursement for dates of service between 11/1/2012 and 3/31/2013	50,000
Gross Reimbursement Per PS&R Less Sequestration Amount dates of service between 4/1/2013 and 10/31/2013	294,000
Sequestration Amount Per PS&R	6,000
Gross Reimbursement Per PS&R	350,000
Number of Beneficiary Count	3

Lines #

Aggregate Cap Calculation

Aggregate Cap calculation (3*26,157.50)

$ 78,472.50

Gross Reimbursement Per PS&R Less Sequestration Amount Per PS&R (dates of service between 11/1/2012 and 10/31/2013)

$ 344,000.00

Sequestration amount Per PS&R

$ 6,000.00

Gross Reimbursement Per PS&R

$350,000.00

Hospice cap pre-sequester overpayment (Line 4 -Line 1)

$271,527.50

2% of the pre-sequester Overpayment Amount (line 5 * 0.02)

$5,430.55

Lesser of Line 3 and Line 6

$5,430.55

Revised Overpayment Amount (Line 5 - Line 7)

$266,096.95

Hospice cap overpayment to be demanded

$266,096.95

Sequestered amount for payments made up to the Cap (Line 3 -Line 6)

569.45

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Sequestration — Impact on Hospice Aggregate Cap Calculations

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