Transcript Document

The Medicare Hospice Benefit
and Medicare Part D
April 18, 2014
Janis Bivins, RN
Marilyn Tatro, RN
John Gochnour, Esq.
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The Medicare Hospice Benefit
◦ Patient is eligible for Medicare Part A;
◦ Patient is certified as terminally ill: which is a
prognosis of six months or less if the illness runs
its normal course;
◦ Elects to receive hospice, and agrees to waive rights
to curative treatment for terminal illness.
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-42 C.F.R. 418.20
Hospice Services covered by the Benefit:
◦ services that are reasonable and necessary for the
palliation and management of the terminal illness
and related conditions. 78 F.R. 27827
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Includes: nursing care; physical therapy;
occupational therapy; speech- language
pathology therapy; medical social services;
hospice aide services; physician services;
homemaker services; medical supplies
(including drugs and biologics)…
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“Hospices are required by Section
1861(dd)(1)(e) of the Act to furnish all drugs
and supplies related to the terminal illness
and related conditions.” 73 F.R. 32088,
32145
“Drugs and Biologicals related to the
palliation and management of the terminal
illness and related conditions, as identified in
the hospice plan of care, must be provided by
the hospice…” 42 C.F.R. 418.106
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CMS’s Concern: Drugs covered under the
Medicare Part A Hospice benefit are being
inappropriately billed to Part D.
2010: 750,590 hospice beneficiaries enrolled in
Part D
198,543 of those beneficiaries received 677,022
prescriptions believed to be appropriately
covered under Hospice benefit
Cost: $33,638,137 by Part D; $3,835,557
unnecessary copayments
◦ Key OIG Issue Areas: analgesics, anti-nausea, laxatives,
anti-anxiety. Since September 2012 Medicare has
encouraged sponsors to obtain Prior Authorization (“PA”)
for these drugs.
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Hospice is responsible for drugs that are (1)
reasonable and necessary for the palliation
and management of the (2) terminal illness
and related conditions.
Two key Questions:
◦ What is a related condition?
◦ What is reasonable and necessary?
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We are responsible for determining the
answer to both.
We simply must be able to explain why and
how we reached our conclusion and show
thorough documentation supporting the
decision.
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Reviewed on a case by case basis: “The unique physical
condition of each terminally ill individual makes it
necessary for these decisions to be made on a case–bycase basis.”
CMS’s aggressive position:
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Question:
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◦ The statutory waiver is broad and “hospices are required to
provide virtually all the care that is needed by terminally ill
individuals.” CMS Letter Dec. 6, 2013
◦ “When an individual is terminally ill, many health problems are
brought on by underlying condition(s), as bodily systems are
interdependent.” 78 F.R. 27826
◦ Therefore: “Unless there is clear evidence that a condition is
unrelated to the terminal illness, all services would be considered
related.” 78 F.R. 27827
◦ Can we provide clear evidence documenting that
the drug should be considered unrelated?
The hospice physician and inter-disciplinary
team (“IDG”), in consultation with the
patient’s attending physician—determine if a
drug is reasonable and necessary.
***If a drug is determined to be related, but
not reasonable and necessary,
whether because it is ineffective
or causes negative systems,
Medicare prohibits the hospice or
Part D from paying for the
Medication.
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Hospice Formulary:
◦ Hospice may determine what drugs it will carry on its
formulary.
◦ Hospice may work from its formulary first in finding
medications to provide pain and symptom relief for their
patients.
◦ But prescribed medications must meet the needs of the
beneficiary. If formulary drugs are not working the
hospice must provide an alternative drug if the
formulary drug is not providing the necessary relief.
However, if a patient requests a specific drug,
but the IDG determines that a formula drug
would work equally well, the hospice need not
pay for the requested drug.
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If a medication is requested but hospice
determines that it is not reasonable and
necessary:
◦ Hospice does not provide the drug—No Advance
Beneficiary Notice of Non-coverage (“ABN”)
◦ Hospice provides the drug—must provide ABN
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Beneficiary can appeal the decision by filing
CMS 1490s
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Drugs used for the treatment of the terminal illness or related
conditions prior to election:
Is the drug
reasonable and
necessary for
treatment and
palliation of the
terminal illness or
related condition
(i.e. is it effective
as part of the
POC)?
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Yes.
No.
Hospice
must
provide as
part of Part
A Benefit
If patient
continues to
use patient
is liable
REMEMBER: Plan of Care (“POC”) includes all drugs necessary for
the palliation and management of the terminal illness and related
conditions—even if the drug was used prior to election.
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“Part D Sponsor should place beneficiarylevel PA requirements on all drugs for hospice
beneficiaries to determine whether drugs are
coverable under Part D.” CMS March 10, 2014
Clarification Letter
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Hospice initiates communication with Sponsor
prior to claim submission (best practice: at time
of election).
◦ Notifies sponsor of hospice election.
◦ Identifies any drugs covered by Part D and provides
explanation of why the drugs are unrelated to terminal
illness.
 Sponsor accepts hospice’s explanation as satisfactory to
satisfy PA requirements.
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Hospice can identify a patient’s Part D plan by
requesting their pharmacy do an electronic
eligibility query to CMS.
May initiate communication through sponsors 24
hour pharmacy help desk.
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If hospice provider or prescriber does not
respond: Part D can’t rule out that the claim is
covered by Part A Hospice benefit, therefore,
Sponsor will deny the claim.
No specific PA form in 2014 (see list of
information)
Respond as quickly as possible for coverage
determinations
Coverage determination time frames:
◦ Expedited request: 24-hours after explanation provided
◦ Standard request: 72-hours after explanation provided
Sponsor retroactively
reviews medications
provided during
election period after
receiving NOE
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Drug related to terminal
condition—Hospice is liable
Drug unrelated to terminal
condition—Hospice or
prescriber provides PA
information. Part D pays
Payment is arranged between Part D Sponsor,
hospice, and beneficiary.
Timely Filed NOE can help avoid issues
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CMS recognizes disputes will arise: They propose to
establish an independent review board to make a
final determination on whether a drug is related or
unrelated.
2014 process:
◦ Hospice and Part D must coordinate their benefits
◦ Hospice/Prescriber should immediately provide PA
documentation
◦ Part D Sponsor should accept and maintain documentation
that a drug is unrelated
◦ Part D Sponsor can flag a claim for retrospective review
once the independent review process is in place
◦ Part D Sponsor and Hospice should negotiate retrospective
recovery if sponsor paid for drugs after effective date of the
election, but prior to notification from CMS
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Review Documentation related to terminal illness: The
clarification letters require hospice providers to more thoroughly
consider and better document whether conditions and
prescribed medications are unrelated to underlying terminal
illnesses.
File NOEs ASAP: Thereby notifying Part D sponsors of Hospice
election and avoiding retrospective recoveries.
Refine communication methods with Part D Sponsors. Who will
initiate communication and at what point?
As soon as you know a patient has an unrelated medication
need—initiate a conversation with Part D Sponsor.
Adopt new consent language to reflect change in approach to
beneficiary liability.
Discuss the role of your medical director in helping determine
whether conditions are related.
Must document any verbal Prior Authorizations