Eli's Hospice Insider

Published on Wed Oct 15, 2014 PDF

Will your claims withstand eligibility review?

The feds appear to be laying the groundwork for potential expanded review of physicians’ eligibility determinations for hospice patients, according to the 2015 final payment rule.

“There must be a clinical basis for a certification,” the Centers for Medicare & Medicaid Services notes in the final rule published in the Aug. 22 Federal Register. “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 expectancy will be included in the beneficiary’s medical record and available to the MACs when requested,” the National Association for Home Care & Hospice 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.