Eli's Hospice Insider

Published on Mon Aug 18, 2014 PDF

Prior authorization is still in effect for analgesics, antinauseants, laxatives, and antianxiety drugs.

Months of frustration over prior authorization for hospice patients’ medications should ease with new CMS guidance on the matter.

In a July 18 memo to Part D sponsors, the Centers for Medicare & Medicaid Services “strongly suggests” that the drug plans drop PA edits for hospice patients’ drugs, except for four categories. This is an about-face from CMS’s March 10 guidance to implement PA for all hospice patients’ drugs starting May 1 (see Eli’s Hospice Insider, Vol. 7, No. 5).

The problem: Under the PA policy, “the operational challenges associated with prior authorizing all drugs for beneficiaries who have elected hospice to determine whether the drug is coverable under Part D have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries,” acknowledges CMS in the memo.

In July’s Open Door Forum for home health and hospice providers, one hospice rep voiced her frustration with securing drug coverage for discharged hospice patients. Cheryl Sweetin with Carrefour Associates complained to CMS that the 11 hospice locations she manages were having lots of trouble with discharged patients being unable to get Part D plans to pay for their drugs.

Patients being discharged were having a “horrific time” trying to get their drugs after discharge, Sweetin said in the call. “We’re at … our wit’s end, trying to help patients who are discharged to get their meds.”

At the time — prior to the July 18 memo — CMS’s Randy Throndset noted that the agency’s Part D staffers had been receiving complaints and questions related to the requirement.

In fact, the “vast majority” — 70 percent — “of all medication-related hospice beneficiary complaints submitted during the month of May 2014” were “related to issues regarding the beneficiary’s Medicare hospice election/termination,” CMS notes in the memo. “The majority of these complaints pertained to beneficiaries who claimed their Medicare hospice benefit had terminated, but were still reflected as being in a Medicare hospice benefit period in CMS’ systems and therefore were subject to a beneficiary-level prior authorization edit.”

“Dying patients either revoked or refused the hospice benefit, foregoing this compassionate care, in order to maintain access to medications unrelated to their terminal prognosis,” reports the National Hospice and Palliative Care Organization. Under PA, “dying hospice patients and their family caregivers found themselves caught in the middle of the policy which many in the hospice community called well-intentioned yet misguided,” NHPCO says in a statement.

Under the PA policy, “hospice patients and their families have suffered significant and sometimes harmful delays in securing needed medications,” the National Association for Home Care & Hospice notes in a statement.

The solution: To alleviate these and other PA-related problems, CMS is telling Part D plans to limit PA edits to just four categories of drugs: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). These drugs were highlighted in a 2012 HHS Office of Inspector General report as “nearly always covered under the hospice benefit,” CMS says in a notice posted to its website.

“This is great news for hospice providers, as well as beneficiaries,” cheers consultant Susan Balfour with Hospice Fundamentals in Mesa, Ariz. The policy change “will go far in alleviating the frustrations caused by the hospice PA process,” Balfour tells Eli.

“The action will bring marked relief to hospice patients and their hospice providers,” Andrea Devoti, NAHC’s chairman of the board of directors, says in the trade group’s statement.

“We are pleased that CMS has taken this step,” NHPCO praises. “It will reduce the confusion for hospice providers and will allow patients to get their medications when they need them,” NHPCO’s J. Donald Schumacher says in a release.

“We are very happy that CMS has chosen the best possible course to ensure both accountability and high-quality hospice care,” agrees NAHC’s Val Halamandaris.

Relief right away: The memo contains good news for your patients’ drug claims currently held up in the PA system. “We recognize that coverage determinations will be pending for some previously rejected claims for drugs other than those in the four categories,” CMS says. “Since these claims should no longer be subject to hospice PA reject edits, the drugs should be considered covered under the Part D benefit without the sponsor obtaining documentation regarding the relatedness of the drug.”

Note: The 13-page memo is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2014-PartD-Hospice-Guidance-Revised-Memo.pdf.