Update: March 10, 2014 - Please note that today CMS released the Final 2014 Guidance related to hospice and Medicare Part D. Weatherbee will publish a review of the Guidance and an update to this blog post shortly.
As of March 1, 2014, Medicare Part D providers will no longer pay for medications that are (or may be reasonably assumed to be) related to a patient’s primary hospice diagnosis and the comorbid conditions that are contributing to his or her terminal status. Rather, hospice providers will be responsible for covering all of the medications that are needed to manage and/or palliate end-of-life symptoms appropriately and effectively. For example, medications for symptoms such as those listed below would likely need to be covered by hospices, regardless of the patient’s primary diagnosis.
- Oral/pharyngeal secretions
- Wounds/pressure ulcers
Although NHPCO is still in dialogue with CMS regarding this issue and expects final guidance will be published imminently, here are some best practice recommendations you may want to consider implementing at your hospice:
- Ensure that well-defined processes are in place to ascertain and document all hospice-covered care, treatment, and services (e.g., drugs, DME, supplies, referrals, etc.).
- Establish, at admission, the most appropriate hospice-qualifying diagnosis (based on referral info; clinical presentation; medical, surgical, and treatment history; burden of illness; disease trajectory; current medications; etc.).
- Identify and transcribe all other diagnoses listed on the referral, in the patient’s clinical records, in the patient/family verbal history, etc.
- Determine which diagnoses are clearly unrelated to the primary hospice-qualifying diagnosis and document and code accordingly. If uncertain how to categorize diagnoses, seek immediate guidance from a hospice physician in order to complete this process upon admission.
- Categorize all the additional diagnoses, as follows:
- Secondary Conditions (i.e., conditions that are a complication of, and/or occur as a result of, the primary condition).
- Related Comorbid Conditions (i.e., conditions that result directly from the terminal diagnosis, or are interconnected with the primary diagnosis, in a manner that strongly influences prognosis).
- Other Comorbidities (i.e., medical conditions that exist simultaneously with, but are independent of, the primary condition).
- Ensure that there is an appropriate, consistent methodology for – and a clearly communicated expectation of – hospice physicians to legibly document any coverage exceptions, and their rationale, with regard to unrelated/uncovered medications.
Ensure that any conflicts or questions related to your hospice’s coverage determinations are resolved quickly and documented in the patient’s clinical record.
Consider utilizing a pharmacist or hospice physician to help guide decisions about needed and/or prescribed therapies. For example:
- Indications for use
- Evidence for use
- Risk vs. benefit
- Relationship to the patient’s hospice plan of care
- Guidance regarding safe discontinuation
- Communicate all coverage-related decisions with patients/families, all contracted vendors/pharmacies, care facilities, and your billing and accounts payable departments.
- If a patient/family decides to continue a “related” but “uncovered” medication, they must be informed that they – not Medicare Part D – may be responsible to pay for that medication.
- Revisit all coverage-related decisions if a patient’s hospice-qualifying diagnosis changes and/or if the patient’s condition and palliative care needs change during the course of care.
- Review and approve pharmacy and other bills to ensure that the appropriate payer is identified.
- Review documentation in the contracted care facility’s clinical record to ensure that the appropriate payer is identified (this is especially important if the care facility changes medications between the hospice nurse’s visits, especially if the facility fails to consult the hospice regarding the need for said changes).
Although hospices can (and should) adopt formularies to help guide treatment decisions, coverage determinations cannot be driven by said formularies.
Lastly, provide staff education regarding how to make appropriate coverage determinations and conduct ongoing clinical record audits to assure compliance (including, but not limited to, whether documentation clearly articulates the rationale for non-coverage).
In summary, it is of paramount importance to involve hospice physicians in making coverage determinations with regard to care, treatment, and services. This issue is both time sensitive (as billing and payment responsibilities commence on the day of admission) and financially pivotal (as a hospice’s cash flow and long-term viability may be significantly impacted by inaccurate coverage determinations).
To assist hospices with this and other regulatory and operational challenges, Weatherbee is pleased to announce its new Physician Advisory Services. Your hospice physicians and clinical leaders can arrange to speak with one of our highly qualified Physician Consultants and receive expert guidance in real time. To learn more about this valuable new service, please call 1-866-969-7124 or email us at firstname.lastname@example.org.
- Weatherbee Resources Physician Advisory Services
- CMS Open Door Forum Meeting Agenda 3/5/14 features Part D
- CMS Memorandum: Part D Payment for Drugs for Beneficiaries Enrolled in Hospice
- NHPCO Responds to to CMS Part D Clarification
Posted by Joy Barry, RN, M.Ed., LNC, President, Weatherbee Resources, Inc.