Hospice Care Reimbursement is as Vulnerable as the Patient it is Designed to Cover

Hospice care provides terminally ill individuals palliative care (relieving pain and suffering) as opposed to traditional medical care aimed at curative treatment (Federal Register 42 CFR 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.

Medicare has been focused on the medical necessity of all inpatient services and GIP (general inpatient) hospice care 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 status also exempts the DRG payment from Medicare’s post-acute transfer DRG rules.

The patient electing hospice care should only be placed in GIP hospice if the care cannot be provided at home. This means the 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 claims for patients assigned to the GIP hospice level of care, 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 providers under a magnifying glass.

Hospice programs should ensure that medical necessity is met based on recognized 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 GIP hospice care can help hospice providers withstand scrutiny by Medicare.

What can be done to ensure compliance as clinical reviews of the hospice provider community increase? There is no “one size fits all” approach. Instead, best 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. Use the findings to implement changes and/or corrective action with the focus on medical necessity and compliance. As with all compliance plans, corrective action must be implemented, recorded, tracked and addressed when issues arise.