• Always more than a little confusion about them within the hospice community
• Important from many perspectives
– Beneficiary rights
– Regulatory compliance
– Business
• Now growing curiosity from policy, regulatory and investigatory quarters
20.2.1 - Hospice Discharge
“Once a hospice chooses to admit a Medicare beneficiary, it may not automatically or routinely discharge the beneficiary at its discretion, even if the care promises to be costly or inconvenient, or the State allows for discharge under State requirements.”
Medicare Benefit Policy Manual Chapter 9
The Regulations
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A. General Provision and DefinitionsB. Eligibility, Election and Duration of BenefitsC. Conditions of Participation – Patient CareD. Conditions of Participation ‐ Organizational
EnvironmentE. Conditions of Participation – Removed and
Reserved F. Covered Services G. Payment for Hospice CareH. Coinsurance
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The Fundamental Difference?
Which party initiates the action
– The hospice provider can discharge the patient only for limited reasons
– The patient can revoke the benefit at any time and for any reason
Regardless of the route, the end result is the same
– Beneficiary is no longer receiving services under the Hospice Medicare Benefit
– Full Medicare coverage for the terminal diagnosis is restored
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– A summary of the patient's stay including treatments, symptoms and pain management;
– The patient's current plan of care;
– The patient's latest physician orders; and
– Any other documentation that will assist in post‐discharge continuity of care or that is requested by the attending physician or receiving facility
Door #1 §418.28
1. Beneficiary can revoke at any time
2. Beneficiary or representative must complete a revocation statement
3. Hospice must file a NOTR within 5 days
Revocation: Important Points
1. Must complete the revocation statement in writing—no accommodation for a verbal revocation
2. Cannot backdate a revocation3. No such thing as a “revocation by action”4. A hospice may never “revoke a patient” 5. A hospice has a responsibility to counsel the beneficiary
on the availability of revocation6. The beneficiary does not have to provide a reason for
revocation7. Hospice documentation should include the
circumstances around the revocation
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2. Second change would require revocation or D/C (if patient leaving service area) with a re‐election
3. Beneficiary must file statement that includes the
a. Name of original hospiceb. Name of new hospice c. Date the change is to be effective
Transfers: Important Billing Points
Establish billing to billing communication – E‐mail agreed upon details to the other party for confirmation
– Document carefully for your records
– No requirement to file 8XA (NOE) as benefit period is already established
Transfers: Important Billing Points
• Sending Hospice: Review requirements for transfer claim carefully
• Receiving Hospice– Must file an 8XC Notice of Change (NOC), prior to submitting your first
claim. Will not be accepted until after sending hospice has submitted their final claim.
– Make sure you see the Election of Benefits and the Certification of Terminal Illness. Pay attention to F2F status.
• Both providers will be paid for day of transfer• No requirement for a new election of benefits; if you do one make sure dates of the existing benefit period are maintained.
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Eligibility for the hospice Medicare benefit requires a life‐expectancy of 6 months or less. If the hospice determines that a beneficiary no longer meets that requirement they must discharge.
Medical Ineligibility: Important Points
Hospices are required to continue to evaluate eligibility during the period the beneficiary is under care and to discharge if no longer eligible
May be at the end or in the middle of a benefit period
Specific beneficiary notice is required; will be covered in Part 2 of the presentation
Medical Ineligibility: Discharge Planning
CMS notes: ”Discharge is not expected to be the result
of a single moment that does not allow time for some
post‐discharge planning”
– When there are indications of improvement in the
individual’s condition such that the patient may soon no
longer be eligible, then discharge planning should begin
– Discharge planning is expected to be a process, and
planning should begin before the discharge date
– Document prudently
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• Beneficiaries that are admitted to a hospital within the service area with which the hospice does not have a contract
Out of Service Area: Important Points
• What about beneficiary leaving service but planning on returning? Discharge or leave on service?
• Travelling patient contracts
Admissions to Non-Contracted Hospitals
When the definition was expanded to include this situation Medicare’s expectation was that the hospice provider would “consider the amount of time the patient is in that facility before making a determination that discharging the patient from the hospice is appropriate”
What exactly does that mean?
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D/C may be due to being admitted to a facility with which the hospice does not have a contract
– Document attempts to establish contract
– If not discharged, beneficiary will be liable for the facility charges
– Re‐admit after discharge; if third or subsequent benefit period will need a F2F
Door #5 §418.28
There was no provision for discharges for cause until 2005.
Discharge with Cause: Important Points
• Each hospice must formulate its own discharge policy and apply it equally to all patients
• Must determine the meaning of “patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired”
• Notify MAC (via billing codes) and state survey agency (via communication of their choice) of any discharges for cause
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Patient is leaving your service area and moving to New Mexico to live with his son who is driving to the Carolinas to pick him up. The son has contacted a hospice in New Mexico and, following the conversation, would like to use them.
҉Which door will the patient be taking?
Case Example 2
Patient with end‐stage COPD has been under hospice care for 2 months. The family has been instructed to call the hospice on‐call number instead of 911 when the patient's condition changes but, since admission, the patient has had 4 ED visits. The last one happened yesterday.
҉ Does this open the discharge with cause door?
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Case Example 3Your hospice is located in an area with a large number of hospices and you have been unable to execute a contract for GIP with any hospitals. You do have contracts with two SNFs but there have been some problems with the quality of care provided to hospice patients experiencing rapid symptom changes. You have a number of live discharge followed by immediate readmissions due to this situation.
҉What are the potential problems and what do you do about them?
The Two Key Medicare Beneficiary Notices
1. The Fee For Service Expedited Determination Notice
2. The Fee For Service Advance Beneficiary Notice of Noncoverage
Actions of a Prudent Hospice™
• Everyone understands the difference between a discharge and revocation
• Ability to explain the benefit and the right of revocation is treated as a basic competency and tested periodically
• A Discharge with Cause policy exists and is applied equally to all patients and families
• The IDT and the attending physician are involved in any each step of the process
• True attempts to solve any problems are made
• Documentation in any discharge or revocation situation is textbook perfect
• The numbers of discharges and revocations are– Monitored and attempts are made to decrease them – Tracked by team
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§ 418.28 Revoking the election of hospice care.
(a) An individual or representative may revoke the individual's election of hospice care at any time during an election period.
(b) To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information:
(1) A signed statement that the individual or representative revokes the individual's election for Medicare coverage of hospice care for the remainder of that election period.
(2) The date that the revocation is to be effective. (An individual or representative may not designate an effective date earlier than the date that the revocation is made).
(c) An individual, upon revocation of the election of Medicare coverage of hospice care for a
particular election period-- (1) Is no longer covered under Medicare for hospice care; (2) Resumes Medicare coverage of the benefits waived under Sec. 418.24(e)(2); and (3) May at any time elect to receive hospice coverage for any other hospice election periods
that he or she is eligible to receive.
(d) When the hospice election is ended due to revocation, the hospice must file a notice of termination/revocation of election with its Medicare contractor within 5-calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary.
[79 FR 50509, August 22, 2014]
Important Points about Revocation
1. Must complete the revocation statement in writing—no accommodation for a verbal revocation
2. Cannot backdate a revocation 3. No such thing as a “revocation by action” 4. A hospice may never “revoke a patient” 5. A hospice has a responsibility to counsel the beneficiary on the availability of revocation 6. The beneficiary does not have to provide a reason for revocation 7. Hospice documentation should include the circumstances around the revocation
Notes
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§ 418.30 Change of the designated hospice.
(a) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received.
(b) The change of the designated hospice is not a revocation of the election for the period in which it is made.
(c) To change the designation of hospice programs, the individual or representative must file, with the hospice from which care has been received and
with the newly designated hospice, a statement that includes the following information: (1) The name of the hospice from which the individual has received care and the name of
the hospice from which he or she plans to receive care. (2) The date the change is to be effective.
Important Points about Transfer
1. One transfer allowed per benefit period 2. Second change would require revocation or D/C (if patient leaving service area) with and re-
election 3. Beneficiary must file statement that includes the
a. Name of original hospice b. Name of new hospice c. Date the change is to be effective
Billing & Technical Billing Requirements Points 1. Must be billing to billing communication; e-mail agreed upon details to the other party for
confirmation 2. Document carefully (including person to whom you talked) for your records 3. No requirement to file 8XA (NOE) as benefit period is already established 4. Sending Hospice: Review requirements for transfer claim carefully 5. Receiving Hospice
a. Must file an 8XC Notice of Change (NOC), prior to submitting your first claim. Will not be accepted until after sending hospice has submitted their final claim.
b. Make sure you see the election and the Certification of Terminal Illness. Pay attention to F2F status.
6. Both providers will be paid for day of transfer 7. No requirement for a new election of benefits; if you do one make sure dates of the existing
benefit period are maintained. Clinical Care
1. Must be clinical to clinical communication 2. Sending Hospice: Forward copy of discharge summary and, if requested, the clinical record 3. Receiving Hospice: Obtain consents, review & update the POC, obtain physician orders 4. If the patient is travelling between hospices, who will be responsible for patient during travel?
If hospices cannot come to agreement, discharge and readmit may be a better option.
Notes
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§ 418.26 Discharge from hospice care.
(a) Reasons for discharge. A hospice may discharge a patient if—(1) The patient moves out of the hospice’s service area or transfers to
another hospice; (2) The hospice determines that the patient is no longer terminally
ill; or (3) The hospice determines, under a policy set by the hospice for the
purpose of addressing discharge for cause that meets the requirements of paragraphs (a)(3)(i) through (a)(3)(iv) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. The hospice must do the following before it seeks to discharge a patient for cause:
(i) Advise the patient that a discharge for cause is beingconsidered;
(ii) Make a serious effort to resolve the problem(s) presented bythe patient’s behavior or situation;
(iii) Ascertain that the patient’s proposed discharge is not due tothe patient’s use of necessary hospice services; and
(iv) Document the problem(s) and efforts made to resolve theproblem(s) and enter this documentation into its medical records.
(b) Discharge order. Prior to discharging a patient for any reason listedin paragraph (a) of this section, the hospice must obtain a written physician’s discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.
(c) Effect of discharge. An individual, upon discharge from the hospice during a particularelection period for reasons other than immediate transfer to another hospice—(1) Is no longer covered under Medicare for hospice care;(2) Resumes Medicare coverage of the benefits waived under § 418.24(d); and(3) May at any time elect to receive hospice care if he or she is again eligible to receive the
benefit.
(d) Discharge planning.(1) The hospice must have in place a discharge planning process that takes into account the
prospect that a patient’s condition might stabilize or otherwise change such that thepatient cannot continue to be certified as terminally ill.
(2) The discharge planning process must include planning for any necessary familycounseling, patient education, or other services before the patient is discharged becausehe or she is no longer terminally ill.
(e) Filing a notice of termination of election. When the hospice election is ended due todischarge, the hospice must file a notice of termination/revocation of election with itsMedicare contractor within 5-calendar days after the effective date of the discharge, unlessit has already filed a final claim for that beneficiary.
[70 FR 70547, November 22, 2005; 79 FR 50509, August 22, 2014]
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Important Points about Discharge: Medical Ineligibility 1. Hospices are required to continue to evaluate eligibility during the period the beneficiary is under
care and to discharge if no longer eligible2. May be at the end or in the middle of a benefit period3. Discharge Planning: CMS notes: ”Discharge is not expected to be the result of a single moment that
does not allow time for some post-discharge planning”a. When there are indications of improvement in the individual’s condition such that the
patient may soon no longer be eligible, then discharge planning should beginb. Discharge planning is expected to be a process, and planning should begin before the
discharge datec. Document prudently
Notes
Important Points about Discharge: Out of Service Area 1. May be due to physically leaving the service area either permanently or for a short period
and no travel contract established2. May be due to being admitted to a facility with which the hospice does not have a contract
a. Document attempts to establish contractb. If not discharged, beneficiary will be liable for the facility chargesc. Re-admit after discharge; if third or subsequent benefit period will need a F2F
Notes
Important Points about Discharge with Cause
1. Each hospice must formulate its own discharge policy and apply it equally to all patients2. Must determine the meaning of “patient’s (or other persons in the patient’s home) behavior is
disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability ofthe hospice to operate effectively is seriously impaired”
3. Notify MAC (via billing codes) and state survey agency (via communication of their choice) of anydischarges for cause
4. The hospice must do the following before it seeks to discharge a patient for causea. Advise the patient that a discharge for cause is being consideredb. Make a serious effort to resolve the problem(s) presented by the patient’s behavior or
situationc. Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary
hospice servicesd. Document the problem(s) and efforts made to resolve the problem(s) and enter this
