Eli's Hospice Insider

Hospices can get physician buy-in with a few simple strategies.

Ready or not, hospices have less than a month to comply with the new hospice narrative requirement -- and physicians aren't likely to make it easy on you.

As first proposed in April, the Centers for Medicare & Medicaid Services (CMS) have adopted the Medicare Payment Advisory Commission's recommendation that physicians include "a brief narrative explanation of the clinical findings that support a life expectancy of [six] months or less" when they certify (or recertify) hospice patients as being terminally ill.

Published in the Aug. 6 Federal Register, the final rule includes a few key changes from the proposal.

New way: Mainly, CMS will accept the narrative either as a typed addendum to the certification form or as information entered onto the form. If the narrative is part of the form, it must come directly above the physician's signature. The addendum must also be electronically or hand signed by the physician immediately following the narrative, the final rule outlines.

Required: No matter how physicians supply it, the physician narrative must adhere to these three strict guidelines:

• be composed by the physician performing the certification or recertification and not by hospice personnel;

• include a statement under the physician signature that confirms that the physician composed the narrative based on his review of the patient's medical record or examination of the patient;

• reflect the patient's individual clinical circumstances and not include any checked boxes or standard language used for all patients.

Convince Physicians to Comply

CMS is placing increased emphasis on "assuring that the right care is being provided to the right person at the right time" -- and this narrative is another way of making that happen, points out Heather Wilson, a consultant with Weatherbee Resources in Hyannis, Mass.

Perspective: The requirement is good news or bad news, depending on how you look at it, Wilson says. The good news is that hospices will have "another piece of documentation to use as strong evidence of a patient's initial and continued eligibility," she notes.

Unfortunately, that documentation means wrangling physicians into preparing the narrative. "Your biggest challenge will be convincing physicians to complete the narrative -- and complete it the right way," Wilson predicts. The requirement will also hit medical directors hard as they have limited time with hospices and now must squeeze in more work.

Try this: Educate the physicians you work with about the new requirement and help them understand that the narrative is not something your hospice came up with to give them more work.

Explain the addendum option, which will appeal to physicians who prefer dictation to hand writing.

While you have until Oct. 1 to comply with the new requirement, you can tackle early confusion or pushback before the deadline if you go ahead and modify your certification (and recertification) of terminal illness forms, Wilson suggests.

"We recommend that our clients incorporate the requirement into the form rather than using the addendum to eliminate the risk that one form or the other goes unsigned," Wilson says. If you start with a modified form, physicians may not question your process and you'll have less paperwork to both sign and keep up with.

Hidden penalty: The new requirement could have a "chilling effect" on referrals, Wilson points out. Referring patients to hospice is already a "complex process," and the new narrative requirement adds yet another layer of work. That could cause many referral sources -- many of whom are attending physicians -- to look for other options.

Workaround: Wilson recommends that hospices rely on their medical directors and hospice physicians to complete the narrative rather than involving attending physicians.

This approach will help your referral business and save you money on training.

The bottom line: The physician narrative requirement is designed to "encourage greater physician engagement in the certification and recertification process" to ensure that patients receive the services they need, MedPAC says.

Note: Read the final wage index rule at http://edocket.access.gpo.gov/2009/pdf/E9-18553.pdf.