Eli's Hospice Insider

Published on Sun Oct 14, 2012 PDF

MAC lays out your responsibilities when you turn down a beneficiary's request for a specific medication.

Medicare is emphasizing beneficiaries' right to appeal hospices' drug coverage decisions, and that may mean more scrutiny of how you turn down patients' requests for pricey medications that aren't on your formulary.

Medicare Administrative Contractor NHIC spells out hospices' duties when it comes to drug coverage in a question-and-answer session from a July webinar on administering hospice advance beneficiary notices (ABNs).

Question: Should a hospice use an ABN when a patient refuses a formulary or generic equivalent of a drug?

Answer: NHIC went to the Centers for Medicare & Medicaid Services to get a response to this question, the MAC says. This scenario "is not appropriate use of the ABN," CMS responds. So what is a hospice to do when a patient refuses the hospice-approved drug?

Step 1: Document. Make sure your plan of care shows that the drug you cover would meet the patient's needs. "The plan of care must include all services necessary Center for Medicare Advocacy attorney Gill Deford tells the Times. The CMA represented Back in the case.

The article seems to take Back's wife's hospice, Visiting Nurse Association of the Inland Counties in Riverside, Calif., to task for denying Actiq for the wife's "agonizing pain."

It's disappointing that the court decision "doesn't ensure that people receive a notice of their right to appeal when they enter hospice care, or that any mechanism exists for expedited appeals," Deford tells the newspaper.

Back is unsure if he will move forward with an appeal. "I don't know if I'm ready to start writing letters all over again at this point of my life," he tells the Times. Rather than recovering the money, his interest is "in making sure other people don't have to go through what I've gone through."

Watch out: The columnist ends the piece by asking readers to share similar stories.