Reimbursement for Hospice Services

1. Reimbursement for Hospice Services Gretchen M. Brown, MSW Connie A. Raffa, JD, LLM Susan Swinford, MSW

2. Reimbursement for Hospices Services • Misconceptions about Medicare Hospice Benefit Coverage • Physician Services • Examples of Financial Cost/Benefits of Providing Broader Services • Covering the Cost of Liaison Nurses • Compliance Issues Related to Hospice Services

3. Misconceptions • Patients must have DNR to access hospice. In fact no medicare provider can deny service based on DNR status. • Once a patient revokes the HMB, he cannot receive hospice care again. Patients can return to hospice care.

4. Misconceptions • After 6 months on the hospice benefit, the patient is no longer eligible for hospice care. Patients are eligible for hospice as long as they have a prognosis of six months or less if the disease process proceeds on its normal course. • When a patient goes to a hospital, hospice services cease. Under the HMB, the hospice care continues if the bene uses a contract hospital; the hospice coordinates care and discharge planning

5. Misconceptions • Patients who revoke or are discharged from hospice are “on their own.” Regardless of the reason a patient leaves hospice, Medicare requires hospice to facilitate transition to another provider. • Managed care doesn’t pay for hospice. MCOs decide about coverage for services and timing of eligibility. There is a great variation including MCO’s that provide hospice care directly. MCO’s must offer hospice.

6. Misconceptions • Once a patient elects hospice, he may no longer access other health insurance. When a Medicare patient elects hospice all care related to the terminal illness is covered by hospice. Medical problems unrelated to the terminal illness are covered under regular Medicare/Medicaid. Private insurers vary.

7. Misconceptions • Self insured companies don’t pay for hospice. Each self insured companies makes a decision about whether and how to offer hospice services. • Can hospice agencies bill for Nurse Practitioners services? No NP services are only billable to Medicare Part B when provided on behalf of the non-employed attending physician.

8. There are a variety of misconceptions and misinformation about physician services. Here’s the scoop…

9. Who is the Attending Physician? Patient’s choice MD or DO NOE

10. An Attending Physician Can Be… Non-employee -no relationship with the Hospice Employee -Employed -Volunteered -Contracted

11. What are Other Physicians Classified As? Any physician other than the attending physician rendering services related to the hospice patient’s terminal illness or related conditions are considered as consultants. ---Agreement with the hospice agency

12. Agreements with Consulted Physicians • Written Agreement • Identify Services • Stipulation of Authorization from the Hospice • Documentation Requirements • Qualifications of Personnel • Financial Responsibilities • Professional Management Responsibilities

13. How are the Services Categorized ?  Professional Services  Administrative ServicesTechnical Services

14. Professional Services Actual procedures performed by the physician as designated by the appropriate CPT Code Only separately billable services

15. Administrative Services Participating in the establishment, review, and updating of the Plan of Care (POC) Care Plan Oversight Supervising care and services Evaluating therapies Assessing need for treatment changes

16. Technical Services X-rays, labs, and any other non-professional services Reimbursed through the hospice’s daily rate Reimbursement from the hospice is based on an agreement with the physician

17. Reimbursement for a Non-employee Attending Physician Medicare Part B for professional services Medicare Part B for Physician Care Plan Oversight Technical services are covered under hospice’s daily rate 80% Medicare payment and 20% patient coinsurance

18. Reimbursement for an Employed Attending Physician Physician bills Hospice  Verify service dates, diagnosis being treated, and service(s) performed Medicare Part A will reimburse hospice 100% of the Medicare allowable amount Hospice reimburses the physician based on agreement between both parties ---Medicare is not involved

19. Reimbursement for a Consulting Physician • Same as an employed attending physician • Contract must be on record prior to rendering the service, and before filing the professional charges to Medicare Part A. NOTE: Medicare Part B will not reimburse any physician rendering related services to a hospice patient other than the non-employee attending physician.

20. Administrative Services Provided by the Non-employed Physician • Care plan Oversight is billed by the physician to the Medicare Part B Carrier • At least 30 minutes face-to-face services must be provided in the month. • Medicare does not pay for oversight services provided in the nursing home • Billing requires the hospice Medicare provider number.

21. Other Situations Rural Health Clinic Physicians Normally billed to Medicare Part A on the clinic bill Hospice must contract with the physician and bill as a consultant physician Nurse Practitioners NPs are only billable if providing services on behalf of the non-employed attending physician Billed to Medicare Part B Carrier

22.  HCFA Publication 21, Section 303.2 All services non-related to the terminal condition and related conditions are billable to traditional Medicare for coverage consideration Unrelated Physician Services

23. What happens if the Patient Changes their Attending Physician? Notify Medicare Part A on the next claim submitted for processing Notify Medicare Part B by sending a copy of the original NOE with the original attending physician crossed out and enter the new attending physician, UPIN number, and the effective date of the change.

24. Non-Employee Attending Physician Consultant Physician Employee Attending Physician Professional and Administrative Services Technical Services Professional, Administrative and Technical Services Professional, Administrative and Technical Services Physician Bills Medicare Part B Physician Bills Hospice Agency Physician Bills Hospice Agency Physician Bills Hospice Agency Physician Billing Flowchart

25. Hospice Physician Billing Chart

26. Financial Success for Hospice closely related to size • HMB causes hospice to work like managed care. The more patients a program has to spread cost, the more financially successful the hospice becomes. • Economies of scale can be realized for contracts or purchase of drugs, supplies, DME. • Administrative staff cost is reduced per patient day with additional patients.

27. Cost Benefits to Broader Access • Patients with non-cancer diagnosis. LMR Policies define some criteria for admission. More experienced hospice may use them only as guidelines. • Patients in the nursing home benefit from hospice (if not using SNB). • Inpatient care increases number of beneficiaries.

28. Hospice Care Center • 17 bed acute care and respite • Located in acute care hospital in licensed medical/surgery beds • Space is leased to the hospice • Average Daily Census 14 • ALOS 8 MLOS 6 • About 70 admissions per month • About 50 deaths/ 20 discharges

29. HCC Patients--- New to Hospice • 1998 patients direct admitted to the Hospice Care Center numbered 214 • 1999 these patients numbered 212 • 2000 direct admits numbered 235 • In 2001 direct admits rose to 319 • Reasons include first year of 17 bed unit, palliative care inpatient consults and popularity of HCC to hospitalists

30. Cost Benefits to Broader Access • Broader view of palliative interventions including some chemotherapy and radiation when appropriate. Cost may not be substantial related to an increased LOS. • For community programs, opening bereavement counseling to persons with losses that did not use hospice can increase contributions and hospice use.

31. Additional Benefit The addition of palliative care services may increase both numbers of patients using hospice and can increase the length of stay.

32. Palliative Care to Hospice • 146 unduplicated patients seen in 1999 • 163 unduplicated patients seen in PCC in 2000 • 212 unduplicated patients in 2001 (23% increase) • 79 PCC patients were admitted to HOB • 63 of these patients have died • 13 are still living • 33 were direct admits to HCC

33. LOS of PCC Hospice Patients • 33 PCC patients admitted to HCC (about 52% ) ALOS 25 Median LOS 6 • Half of the direct admits lived less than a week • 75% lived less than a month • The ALOS for PCC patients is 34 days due to bi-modal effect of large % admitted from inpatient to HCC

34. Hospice Contract Issues With Hospitals Short Term Inpatient Care 42 C.F.R. 418.98, 418.302(a)(4), 418.56(e) and State Operations Manual – Pub 7. • Inpatient care for symptom control • Can be provided by a hospice that meets requirements of 42 C.F.R. 418.100, or • A hospital or skilled nursing facility that complies with §418.100 and has a contract with a hospice.

35. Hospice/Hospital Contract For Inpatient Hospice Services Issues • Responsibilities of Hospice • Responsibilities of Hospital • Services • Medical Records • Confidentiality – HIPAA • Orientation and In-service Education

36. Hospice/Hospital Contract For Inpatient Hospice Services Issues • Payment Arrangements • Personnel • Term and Termination • Indemnification/Insurance • Compliance • Access to Books and Records

37. Sample Hospice/Hospital Contract For Inpatient Hospice Services At CAPC Website www.capc.org

38. Funding Liaison Nurses • Liaison nurses can be funded in a variety of ways, depending on the duties of the staff, the capacity and will of the involved agencies. Possibilities include • Local grants • Cost sharing among hospices • Cost sharing between hospice(s) and hospital

39. Considerations • Is hospice a service that is included in the State’s Certificate of Need Regulations? • Does the hospice compete with other hospices for the same service area? • Does the state have an “any willing provider” law?

40. Strategies Used by HOB • UKMC- first grant, then hospice liaison became UK employee with salary supplemented by many area hospices. • CBH- liaison is a HOB employee, CBH contributes about 1/3 of the employees salary, other hospices contribute small amounts. • SJH-hospice and SJH share the cost of the palliative care nurse. She is an employee of SJH.

41. Funding for Liaison Nurse • ARH- Hospice assigns a nurse to work primarily in the hospital, a strategy to manage hospitalized patients. • St. Luke-a hospice team is assigned to admit and manage hospice inpatients in the hospital as part of their duties. The activities do not require full time.

42. More Considerations • When hospices and hospitals are sharing the cost of staff, each needs to insure that each agency is covering the cost, at fair market value, of the services which benefit that agency. For example, the hospital is responsible for discharge planning, the hospice is responsible for managing hospitalized hospice patients.

43. More Considerations (continued) • Agencies need • a specific contract that details the arrangement • May need a time study • Re-evaluate time needs • To avoid charges of inducement • Physicians must consider Stark law

44. Designing a Health Care Compliance Program for Hospices Connie A. Raffa, JD, LLM Arent Fox Kintner Plotkin & Kahn, PLLC 1675 Broadway, 25th Floor New York, NY 10019 Tel. (212) 484-3926 Fax (212) 484-3990 raffac@arentfox.com

45. 1. Compliance Standards & Procedures 2. Oversight Responsibilities 3. Compliance Officer 4. Employee Training Designing a Health CareCorporate Compliance Program

46. Designing a Health CareCorporate Compliance Program (continued) 5. Monitoring & Auditing 6. Enforcement & Discipline 7. Response & Prevention

47. Arent Fox Alert – OIG Publishes Draft Compliance Guidance For Hospices Office of Inspector General’s Compliance Program Guidance For Hospices – October 5, 1999

48. The OIG has identified twenty-nine risk areas for hospices. These risk areas are listed below and explained in great detail in the footnotes to the draft Compliance Program Guidelines. The Arent Fox Alert discusses in greater detail those risk areas highlighted by the OIG. Hospice Risk Areas

49. Hospice Risk Areas • uninformed consent to elect the Medicare Hospice Benefit; • discriminatory admission; • admitting patients to hospice care who are not terminally ill;

50. Hospice Risk Areas • arrangement with another health care provider who a hospice knows is submitting claims for services already covered by the Medicare Hospice Benefit; • under-utilization;