Practice Management Alert

Question: I keep getting palliative care claims rejected because the payer says the care doesn’t meet medical necessity. How can I have a better shot at getting my physicians reimbursed for their work?

Illinois Subscriber 

Answer: Document, document, document. A lot of payers are considering palliative care for payment but need some differentiation to make sure providers aren’t double-dipping, that there’s no crossover, and that payers aren’t overpaying, says  Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

What is palliative care? Fletcher describes it as medical treatment that manages the symptoms and side effects of chronic illnesses — think cancer, stroke, Alzheimer’s disease.

Palliative care and hospice care are not interchangeable terms; they are different services, especially because a provider can deliver palliative care while still pursuing curative treatment, Fletcher says. Hospice care may be similar, in terms of the actual care provided, but hospice care is for patients whose prognoses are terminal.

“The medical necessity to cure or relieve a condition isn’t really there,” Fletcher says.

Important: Once the patient’s palliative care isn’t improving their quality of life as they are being treated for a chronic condition, palliative care may be more of a therapeutic endeavor, which does not necessarily point to medical necessity, she says. That’s why it’s important as a provider to document how the palliative care is improving the patient’s quality of life.

As palliative care is often provided by a team — one or more clinicians, a midlevel provider, a social worker — each provider should document their role in the patient’s care. Each encounter should note what the clinician is managing and what the clinician is doing to improve the patient’s quality of life, Fletcher says. Make sure you know your payer contracts and contract limitations, since many payers limit the visits related to palliative care, she adds.

For example, Medicare usually does not allow more than three overlapping providers, Fletcher says, and tread carefully: While a physician can check in on how another clinician’s prescribed medication is working for a patient, doing so can affect the prescribing clinician’s reimbursement.

Make sure your physicians know how to explicitly define and document their role in any patient’s palliative care. “It’s not your job to go on a fishing expedition and try to figure out who gets what. It’s their job to clearly define what they should be getting or what they should be reimbursed in that care scenario,” Fletcher says.