Medicare Compliance & Reimbursement

Question: A beneficiary’s family has agreed that their family member is ready to be put in hospice care, but I want to make sure I understand how reimbursement/payments work once we, as a practice, “share” the burden of care with a hospice. Please give me the basics.

Codify Subscriber

Answer: A Medicare beneficiary eligible for the hospice benefit may elect hospice care by signing and filing an enrollee election statement with a hospice.

The hospice must complete and submit the notice of election to their Medicare Administrative Contractor (MAC) within five calendar days of the beginning of hospice care.

Important: The hospice assumes full responsibility for palliative care related to that enrollee’s terminal illness and related conditions.

Be aware: The patient waives Medicare coverage for services related to treatment of the terminal illness and related conditions but retains Medicare coverage for services to treat conditions “unrelated” to the terminal illness and related conditions.

For example, Medicare does not pay for:

• Hospice care from another hospice other than the patient-designated hospice — unless provided under arrangement by the designated hospice
• Room and board — unless the hospice arranges the short-term inpatient care
• Emergency room (ER), hospital, or other inpatient/outpatient services; or ambulance transportation — unless the hospice arranges these services, or they’re services “unrelated” to the patient’s terminal illness and related conditions

Reimbursement: The Medicare hospice benefit has four levels of care:

• Routine home care,
• Continuous home care,
• Inpatient respite care, and
• General inpatient care.

Each level has an all-inclusive daily rate (i.e., a per diem amount) that is paid through Medicare Part A.

The per diem payment is intended to cover not only visit costs but also other costs that a hospice incurs for palliation and management of an enrollee’s terminal illness and related conditions.

Remember: Related outpatient services should be provided under arrangements with the respective facility, as Medicare pays the hospice for outpatient services provided to the enrollee as part of the hospice’s per diem amount.

Tip: According to the Centers for Medicare & Medicaid Services (CMS), services “unrelated” to the terminal illness and related conditions should be exceptional, unusual and rare given the comprehensive nature of the services covered under the Medicare hospice benefit.

Patricia Zubritzky, BS, CRCE-I, Contributing Writer, Pittsburgh