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Hospice Series Part 1: Medicare Part D Guidance Creates Significant issues for Hospice Providers


Hospice Series Part 1: Medicare Part D Guidance Creates Significant Issues for Hospice Providers

There has been much confusion in both the hospice and pharmacy industries related to the CMS decision to recover money from providers for medications seemingly related to hospice services. Even with the guidance posted by CMS on its Hospice Center web page on November 5, 2013, many questions abound regarding payment of certain medications and how they may be related or not-related to the terminal illness.  This issue pertains not only to the claims identified for recovery in the CMS Part D Program Integrity memo issued in August 2013,  but also has implications for future payment of medications for patients who are receiving care under the Medicare Hospice Benefit.  It is important to note that Medicare Part D issues will impact not only hospice providers and pharmacies, but also nursing facilities where hospice patients reside as well as hospice patients and families directly.

The November 5, 2013 guidance on the CMS Hospice Center Website reads as follows:

  • "In our 1983 Hospice Care final rule and reiterated in the FY 2014 Hospice Wage Index and Payment rate update final rule,  CMS described it's expectation that hospices are required to provide virtually all the care that is needed for terminally ill patients. Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all services are to be considered related.  In extremely rare instances where the hospice physician determines that a condition is unrelated to the terminal prognosis, it is the responsibility of the hospice physician to document why the patient's medical needs would be unrelated to the terminal prognosis.

  • CMS issued a memorandum on October 30, 2013 entitled "Clarification of Recovery of Part D Payment for Pain Medications for Beneficiaries Enrolled in Hospice." This memorandum provides additional guidance for Part D sponsors on the recovery of payment for drugs. The guidance augments the prior CPI guidance by outlining a consistent approach to financial reimbursement requests by Part D sponsors to hospice providers."

This guidance document instructs Part D plans to recoup payments from hospices for all analgesics paid by Part D to enrolled Medicare hospice beneficiaries back to 2011.  The guidance states:

"Thus, for the purposes of this recovery effort only, we presume that all the drugs were used for the palliation and management of the terminal illness and/or related conditions. They are, therefore, considered to be related to hospice care and thus a case-by-case analysis to determine relatedness is not required."

CMS's approach to this issue has resulted in significant advocacy efforts on the part of the national hospice industry associations who are working diligently to address the concerns of hospice providers across the country. The drug issue has significantly greater implications for hospice providers in balancing the responsibility for the professional management of the care of their patients along with the responsibility of the hospice physician in certification of the terminal illness and the hospice plan of care with clear identification of what is not related to the terminal illness. Simione will discuss further strategies for meeting this requirement in our next article in this series.

While we are awaiting further guidance from CMS, Simione recommends the following strategies for working with your pharmacies, nursing facilities, patients and families:

a. The hospice physician and hospice team should identify which medications which are related as well as those medications which are not related to the terminal illness based on their clinical judgment and results of the comprehensive assessment of the individual receiving hospice care. While it is likely that these medications will correspond with the diagnoses and services that are determined to be either related or not related to the terminal  illness, each medication that is provided should be carefully reviewed in relation to its use for pain and symptom control of the terminal illness.

b. The hospice physician should clearly delineate in the clinical record which medications are provided in relation to the pain and symptom control of the terminal illness as well as those medications that are not related to pain management and symptom control of the terminal illness and the reason the medication is unrelated. While all medications the patient is receiving should be listed, it is especially important to accurately document related and unrelated analgesics, anti-emetics, antianxiety agents and laxatives. Hospices should conduct routine record reviews to insure this information is clearly documented in the clinical record.

c. Hospices should share the listing of an individual patient's related and unrelated medications with the patient/family/caregivers, pharmacy, and nursing facility (if applicable) with a reminder to other providers not to bill Medicare Part D for the medications determined by the hospice physician to be related to the terminal illness.  This related/unrelated medication listing should be reviewed with the pharmacy, patient/family/caregivers, and nursing facility (if applicable) upon initial certification and minimally upon each recertification period.  Future guidance from CMS may indicate a process whereby the hospice provider will also need to notify the Medicare Part D sponsor but this is not required at this time.

d. Hospices should review the listing of related and unrelated medications at each interdisciplinary team meeting and notify the pharmacy, nursing facility or patient/family of any changes.

e. Hospices should closely review their monthly claims closely to insure that only medications provided to the patient that are related to the terminal illness are included on the claim.  This will be increasingly important once line-item billing for medications is implemented with voluntary reporting effective January 1, 2014 and mandatory reporting effective April 1, 2014.  Simione will discuss line item billing along with additional data reporting requirements outlined in CMS CR 8358 in a future article in this series.

f. As a final reminder, the hospice plan of care should be updated as necessary and include all services necessary for the palliation and management of the terminal illness and related conditions, including all medications necessary to meet the needs of the patient.

Contact Simione for further information and to see how we can assist you with your hospice needs; 800-949-0388 or [email protected]