Hospice Patients, Part D Coverage and Analgesics
November 5, 2013 04:21 PM
On October 30, 2013, the Centers for Medicare & Medicaid Services (CMS) sent a memo to all Medicare Part D plan sponsors instructing them to recoup payment directly from hospices for prescription analgesics paid for by the Part D plan during dates in 2011 and 2012 when the beneficiary was enrolled in hospice. The memo is from the Medicare Program Integrity Group and Medicare Drug Benefit C & D Data Group and is a follow-up to other guidance to Part D sponsors released earlier this year, as part of a general CMS effort to ensure that prescription drugs for hospice patients are financed through appropriate areas of Medicare.
The memos provide guidance and instruction to Part D plan sponsors regarding payment for medications for hospice beneficiaries that are paid for by the Part D plans. The instruction is based on analyses conducted earlier this year by the Center for Program Integrity (CPI) of 2011 and 2012 prescription drug event (PDE) records submitted to report Part D payment for pain control medications where the date filled is within the dates of the beneficiary’s Medicare hospice election.
The most recent memo was released in response to clarification sought by Part D plan sponsors and states “…for the purposes of this recovery effort only, we presume that all the drugs were used for the palliation and management of the terminal illness and/or related conditions. They are, therefore, considered to be related to hospice care and thus a case-by-case analysis to determine relatedness is not required. Since the drugs were the payment responsibility of the Medicare hospice, the PDE reflects an overpayment that should be recovered from the hospice…” Again, the payments are for analgesics only.
The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) are concerned about CMS’ blanket statement that all analgesics are presumed related to the terminal (or a related) diagnosis and instruction that case-by-case analysis to determine relatedness is not necessary.
NAHC and HAA are working to share these concerns and dialogue with the appropriate parties on a reasonable approach to addressing payments by Part D plans that should have been paid for by the hospice. Readers can refer to previous coverage of Hospice/Part D issues in the October 24, 2013, issue of NAHC Report .
If hospices receive any requests from Part D plan sponsors requesting payment, preauthorization of hospice patient medications or information about hospice patient enrollment dates please contact us at Katie@nahc.orgor firstname.lastname@example.org.
In the interim, hospices should take the following steps to ensure compliance with Medicare:
Implement or reinforce process for medication review on each regularly scheduled hospice visit to ensure the hospice is aware of all medications the patient is taking. This is particularly important for patients residing in facilities.
Implement or reinforce process for identifying related and non-related medications and communicating this information to the pharmacy and the patient/family.
Conduct routine audits to ensure documentation supporting non-related medications is clear and present in the medical record.
Conduct routine audits to ensure the pharmacy is billing hospice for ALL related medications.
Develop the same processes for supplies and other hospice-related items