Home Health & Hospice Week

Final rule also addresses patient eligibility documentation.

The feds appear to be readying a crackdown on what and how much hospices must pay for when it comes to their Medicare patients — but that initiative isn’t underway quite yet.

In its 2015 final payment rule for hospices, the Centers for Medicare & Medicaid Services reiterates its review of the definitions for "terminal illness" and "related conditions." CMS repeats its definitions from the proposed rule and notes that it will use the numerous comments it received about them in future rulemaking.

What to expect: Experts predict that CMS is planning a major overhaul of what hospices must bundle into their payments — pretty much all of a patient’s drugs, equipment and services at end of life. "Our expectation continues to be that hospices offer and provide comprehensive, virtually all-inclusive care, and with a patient-centered approach," CMS stresses in the rule. "In order to preserve the Medicare hospice benefit and ensure that Medicare beneficiaries continue to have access to comprehensive, high quality and appropriate end-of-life hospice care, we will continue to examine program vulnerabilities and implement appropriate safeguards in the Medicare hospice benefit, when appropriate."

It’s a good sign that CMS isn’t finalizing those definitions for this year, says attorney Marie Berliner with Joy & Young in Austin, Texas. "One of the most significant features of this rule is what is not there — definitions of ‘terminal illness’ and ‘related conditions,’" Berliner tells Eli. "Hopefully, that means that CMS is carefully considering the comments and feedback it has received on these terms, which the industry has understood to be unchanged since the inception of the hospice benefit."

Big impact: Berliner hopes that CMS "ap-preciates the effect that the definitions have on the entire hospice benefit," she says.

Expect to see CMS pay particular attention to Part D drugs’ coverage under the hospice benefit, especially since the agency had to pull back a large portion of its preauthorization initiative (see Eli’s HCW, Vol. XXIII, No. 26).

"Because hospice care is unique in its comprehensive, holistic, and palliative philosophy and practice, we want to ensure that the hospice services under the Medicare hospice benefit are preserved and not diluted, or unbundled in any way," CMS says in the rule.

Will You Withstand Eligibility Review?

CMS also is laying the groundwork for potential expanded review of physicians’ eligibility determinations for hospice patients. "There must be a clinical basis for a certification," CMS notes in the final rule. "A hospice is required to make certain that the physician’s clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course."

In other words, the physician doesn’t have the last word. "While the expectation remains that the hospice physician will determine a beneficiary’s eligibility for hospice, this is not to say that this decision cannot be reviewed if there is a question as to whether or not the clinical documentation supports a patient’s hospice eligibility," CMS clarifies. "The goal of any review for eligibility is to ensure that hospices are thoughtful in their eligibility determinations so that hospice beneficiaries are able to access their benefits appropriately."

Documentation musts: "We expect hospice providers to use the full range of tools available, including guidelines, comprehensive assessments, and the complete medical record, as necessary, to make responsible and thoughtful determinations regarding terminally ill eligibility," CMS spells out.

CMS doesn’t make official proposals on the topic of eligibility, but the agency "expects documentation supporting a 6-month or less life expect-ancy will be included in the beneficiary’s medical record and available to the MACs when requested," the National Association for Home Care & Hos-pice says in its rule analysis for members. "Hospice medical director[s] must assess and evaluate the full clinical picture of the Medicare hospice beneficiary to make the determination whether the beneficiary still has a medical prognosis of 6 months or less, regardless of whether the beneficiary has stabilized or improved," the trade group exhorts.

Note: The final rule is at www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18506.pdf.