Medicare Compliance & Reimbursement

Watch for red flags that could suggest over-utilization.

Hospices that want to weather the coming storm over continuous care can heed these expert tips:

1. Bill correctly. Hospices must understand the requirements of CHC and make sure they are billing the service accurately. For example, if a hospice furnishes even one more hour of aide service than RN or LPN service, it can't bill CHC and must bill the much lower routine home care rate instead.

"Hospice is not meant to be ongoing shift care and used too often," maintains consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO. "Setting a goal as a company to reach a certain percentage of continuous care is not appropriate."

View CMS' specific instructions and clarifications for CHC in its 2003 memo at www.cms.hhs.gov/transmittals/downloads/A03016.PDF.

2. Individualize care plans. Rote care planning may doom hospices' CHC claims, warns attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, WI. "A cookie cutter approach to care planning, where everyone essentially gets the same care, will not fly and may place the hospice at grave risk."

3. Document, document, document. Comprehensive documentation of CHC is a must, stresses consultant Beth Carpenter with Beth Carpenter and Associates in Lake Barrington, IL. "Without appropriate, ongoing, complete justification and documentation for continuous care ... reimbursement for the continuous care services will be denied," she cautions.

4. Tailor ADR responses. Sending in the supporting documentation for medical review may not be enough. Michal recommends including a cover letter that indicates the areas of the medical record that specifically support eligibility.

5. Beware underutilization. While a hospice may court denied claims with over-utilization, survey deficiencies may result from underutilizing CHC, Litwin emphasizes. She cites a recent example of surveyors hitting a client hospice with a deficiency because it admitted a patient for inpatient care rather than "even thinking about doing continuous care," she says. "This agency has been open five years and has never done continuous care. This is a common occurrence."

Hospice patients' interdisciplinary teams and medical directors should evaluate patients for CHC, Litwin recommends. And they should reevaluate the necessity of the care at every eight-hour shift, she says.

6. Educate staff. If hospice staff members don't understand the requirements for CHC, chances are the hospice isn't furnishing it correctly.

Hospices first should check their policies to make sure they are compliant with CHC rules, then inservice staff on this level of care, Litwin counsels. "I have been doing this a lot lately," she remarks.