Eli's Hospice Insider

Published on Mon Aug 18, 2014 PDF

Warning: But your clinical documentation had better tell the whole story.

You may be cheering Medicare’s move to eliminate prior authorization for all but the most-covered drugs for hospice patients, but you still need to follow PA procedures for four commonly used meds.

Limiting PA to just four drugs — analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics) — will “vastly decrease the number of hospice PAs that will be needed,” notes consultant Susan Balfour with Hospice Fundamentals in Mesa, Ariz.

And fulfilling the duties for PA on those drugs should also be easier, thanks to the Centers for Medicare & Medicaid Services’ new guidance on the process.

First: Ideally, “medication information … including whether the medications are related or unrelated to the terminal illness and related conditions, should be provided to the Part D sponsor proactively — meaning before a hospice beneficiary presents a prescription for fill,” CMS explains in a memo issued July 18. A hospice pharmacy can identify a patient’s Part D sponsor with a standard electronic eligibility (E1) query to the CMS Transaction Facilitator, CMS explains.

Second: If the hospice hasn’t provided the info proactively and “a claim has been rejected by a sponsor due to the beneficiary-level hospice PA, the pharmacy or beneficiary may contact the hospice provider for a statement that the drug is unrelated to the terminal illness and related conditions,” CMS says in the memo. “The hospice provider should contact the Part D sponsor to provide an oral or written statement or provide a written statement to the pharmacy or the beneficiary to transmit to the Part D sponsor.”

Third: And that statement is relatively effortless. “The statement may be as simple as a ‘U’ or ‘unrelated,’” CMS says in the memo to Part D plans.

Watch out: Hospices do need to make sure the clinical record backs up their statement, though. “Hospices are expected to maintain a record of the clinical basis for the statement that the drug is unrelated and provide it upon request,” CMS instructs.

It’s important for hospices to remember the documentation requirement, Balfour emphasizes.