Home Health & Hospice Week

Survey woes may lie ahead, experts warn.

New hospice requirements related to medical directors could give providers major administrative headaches.

The Centers for Medicare & Medicaid Services published a final rule in the Nov. 22 Federal Register implementing a variety of new requirements for hospices, including a discharge for cause provision and discharge planning mandate (see Eli's HCW, Vol. XIV, No. 43).

Another major change is the role of hospice medical directors in the admissions process.

Numerous commenters on the proposed rule protested the increased involvement of the medical director in this area. The final rule requires a hospice to admit a patient only on the recommendation of the medical director, after the director has consulted with the patient's attending physician.

When deciding on terminal illness certification, the medical director must consider the patient's terminal illness diagnosis, other health conditions, and "current clinically relevant information supporting all diagnoses," the reg says.

Barrier to admission: Commenters were es-pecially incensed at the requirement that the medical director consult with the attending physician. A direct consultation requirement "would be a needless impediment that would add delays to the start of hospice care," they said.

CMS Makes Key Concessions On Consultations, Documentation

CMS backed down on the requirement, saying "it is not our intent to require a face-to-face or any type of direct consultation between the director and the attending physician." CMS revised the language to indicate that patient information can be obtained from the attending physician through direct consultation or indirectly by a hospice nurse, etc.

CMS also revised language to make clear the medical director doesn't have to possess all medical documentation at the time of admission, but that medical reports can arrive after admission for inclusion in the medical record.

The new requirements are very complex, experts note. "The medical director piece becomes even more tricky when we begin to see how the [state surveyors] actually survey it in the certification process," worries John Mahoney with Summit Business Group in Penfield, NY.

But hospices can take heart from the changes between the proposed and final rule, notes Janet Neigh with the Hospice Association of America. "The medical director/attending physician consultation clarification language should solve the apprehension hospices had about the difficulty of facilitating discussion between the two physicians," Neigh judges.

Hospices have disputed the need for additional admission requirements, notes consultant Heather Wilson with Weatherbee Resources in Yarmouth Port, MA. But she views the new requirements as a good thing for the industry.

Medical review bonus: "We do extensive work with hospices that have had claims denied or are in other sorts of trouble because their documentation does not adequately support the patient's terminal diagnosis," Wilson tells Eli. "The strengthened requirements ... should definitely help hospices be more intentional and scrupulous about ensuring that appropriate documentation is available to support the patient's eligibility." 

Note: The final rule is at www.access.gpo.gov/su_docs/fedreg/a051122c.html.