Home Health & Hospice Week

Tip: Collect hospice patients’ Part D plan information at admission.

Expect the transition to the Part D prior authorization process for hospice patients to be bumpy. The best way to avoid receiving bills for unrelated drugs is to be proactive in the PA process.

Starting May 1, the Centers for Medicare & Medicaid Services will begin requiring Part D drug plans to perform PA on all drugs for hospice patients (see related story, p. 106). Under the new system, plans will automatically reject any drug claim for a hospice patient. When the pharmacy receives the rejection, it will contact the beneficiary or prescriber to determine whether the hospice provider should cover the drug. If the answer is “yes,” the pharmacy will submit its claim to the hospice. If the answer is “no,” the pharmacy will direct the beneficiary or prescriber to contact the Part D plan to start the PA process. Once the Part D plan starts the PA process, the prescriber or the hospice may provide the plan with an explanation of why the drug is unrelated.

CMS has asked Part D plans to include only certain information on their PAforms, CMS’s Deborah Larwood said at the National Association for Home Care & Hospice’s recent March on Washington conference. CMS didn’t have time to issue a required form, but due to its form guidelines, “you should be seeing things that are very similar” from

different plans, Larwood assured attendees.

Problem: Waiting to see whether you hear about unrelated drug claim rejections for your patients could leave you with a real mess. Under CMS’s guidelines, “prescribers who are unaffiliated with the hospice provider, in addition to providing the explanation regarding why the drug is unrelated to the terminal illness or related conditions, should also attest that they have coordinated with the hospice provider and the hospice provider confirmed the unrelatedness of the drug,” the agency says in the memo. So you’ll likely get roped into the process anyway. And if the prescriber’s documentation does not pass muster, the pharmacy will send you the bill for the medication.

And sometimes, due to delays in pharmacy billing, submitting notices of election, or system updates, you won’t receive a bill until long after the patient has died.

Solution: Hospices should take advantage of the ability to proactively contact the Part D plan about their patients, Larwood advised. CMS made that change in response to comments received on the draft policy. The agency received about 130 comment letters on that memo, Larwood pointed out in the conference. “We did pay attention … and tried to be as responsive as we could be,” she said. You should add the step of collecting the patient’s Part D plan information to your admission process, NAHC advises.

Lock Down Part D Plan Info First Thing

You can identify a patient’s Part D plan by simply asking her, or by having the pharmacy run an E1 eligibility query, Larwood noted in an April 8 special Open Door Forum dedicated to the PA process. The query response identifies the plan and provides the plan’s online billing information, as well as the pharmacy help desk phone number. The hospice can initiate communication or fulfill a PA through the sponsor’s 24-hour pharmacy help desk.

Keep tabs: If your patient switches Part D plans, you have to establish contact all over again, Larwood said in response to a question at the NAHC conference. Information will not transfer from one plan to another.