By: Mary Devine, Senior Manager
Kaitlin Torrenzano, Project Analys
Introduction
Hospice care provides terminally ill individuals palliative care as opposed to traditional medical care aimed at curative treatment (42 C.F.R. Part 418). The philosophy of care behind Hospice takes into account all aspects of the patient and their family life providing supportive services and pain relief associated with life-threatening illnesses, issues congruent with end of life and relief from suffering. According to Centers for Medicare and Medicaid Services (CMS), the revised Hospice Conditions of Participation (CoP’s) are “patient-centered, outcome-oriented, and a transparent process that promotes quality patient care for every patient every time" (42 C.F.R. Part 418).
Hospice Care Under Scrutiny in Nursing Homes
While patients who elect Hospice primarily receive care in their home, care can also be provided in nursing homes or Hospice units. CMS introduced a new CoP regarding the relationship between Hospices and nursing homes specifically when Hospice patients are nursing home residents (42 C.F.R. 418.112). The Office of Inspector General (OIG) has highlighted that Medicare is paying more for Hospice care each year. Subsequently, OIG found that nursing homes with high percentages of Hospice recipients receiving care for longer periods should be monitored in an effort to reduce Medicare payments. This scrutiny stems from heightened claims for Hospice recipients in nursing homes not meeting Medicare coverage requirements. In the past CMS has used a problem-focused reactionary approach for quality assurance, whereas now, “the objective is to achieve a balanced regulatory approach by ensuring that a Hospice furnishes health care that meets essential health and quality standards, while ensuring that it monitors and improves its own performance” (42 C.F.R. Part 418). Based on input from those held to or responsible for Hospice regulation and oversight the following determinations were set forth:
- Focus on the continuous, integrated health care process that a patient/family experiences across all aspects of Hospice care, and on activities that center around patient assessment, care planning, service delivery, and quality assessment and performance improvement;
- Use a patient-centered, interdisciplinary approach that recognizes the contributions of various skilled professionals and other support personnel and their interaction with each other to meet the patient’s needs;
- Incorporate an outcome-oriented quality assessment and performance improvement program;
- Facilitate flexibility in how a Hospice meets performance expectations;
- Require that patient rights are ensured; and
- Use performance measurement systems to evaluate and improve care.
(42 C.F.R. Part 418).
With attention to better coordination of care by nursing homes to meet Hospice requirements, long term care residents electing the Hospice benefit are better served as compliance is met.
Concerns with Medical Necessity of General Inpatient (GIP) Hospice Care
Medicare has been focused on the Medical Necessity of all inpatient services and hospice GIP is not exempt from that same scrutiny. GIP Hospice care is reimbursed at four times the rate of hospice home care or respite care. This patient transfer status also exempts the DRG payment from the transfer DRG rules.
These patients electing Hospice should only be placed in GIP Hospice care if their care cannot be provided at home. This means their pain or acute condition cannot be managed appropriately at home and the medical necessity must be clearly documented in the medical record.
Not only will CMS be reviewing this, but so will the RACS. They will be requesting the medical records for GIP hospice patients transferred from hospitals to ensure the medical necessity is supported by the documentation. CMS will also be putting the relationships between the hospital and the hospice under a magnifying glass.
Hospice programs should ensure the medical necessity is met based on the Hospice and Palliative Care guidelines. These guidelines are specific to the criteria of these patients as it relates to: pain, symptom management, psychosocial monitoring and imminent death. Focusing on the needs of the patient prior to accepting them into the GIP hospice care can eliminate the scrutiny Medicare plans to put Hospice providers under.
How Compliance can be Achieved
What can be done to ensure compliance as scrutiny of the Hospice provider community increases?
There is no “one size fits all approach”. Instead, better practice facilities implement customized solutions and processes that properly document physician certification, patient election and medical necessity for each Hospice patient.
As a Hospice provider, it is critical to audit and review processes regularly. Be proactive and incorporate such reviews into the workflow process. Use the findings to implement changes and/or corrective action with the focus driven on medical necessity and compliance. In addition, each provider must be aware of and understand the new CoP guidelines as published by CMS. With all compliance plans, corrective action must be implemented, recorded, tracked and addressed when issues arise.
For more information, please contact Mary Devine at 609-514-1400 or mdevine@besler.com.
References
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Department of Health and Human Services: Centers for Medicare & Medicaid Services, “Medicare and Medicaid Programs: Hospice Conditions of Participation,” Federal Register / Vol. 73, No. 109 / Thursday, June 5, 2008 / Rules and Regulations.
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“Hospice Payment System: Payment System Fact Sheet Series,” Department of Health and Human Services Centers for Medicare & Medicaid Services, ICN: 006817/September 2010.
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National Hospice and Palliative Care Organization “Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Service: A joint project of the National Hospice and Palliative Care Organization and the Center to Advance Palliative Care”, December 2001.
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