CMS to Recoup, Deny Inpatient Hospital Care Claims for Hospice Terminal Diagnosis
November 13, 2013 10:21 AM
The Centers for Medicare & Medicaid Services (CMS) has issued Change Request (CR) 8273, dated November 7, 2013, which instructs the Medicare Administrative Contractors (MACs) to implement a new edit to deny hospital inpatient claims when there is a Medicare hospice claim for the same beneficiary within the same covered period and the principal diagnosis code on the hospital inpatient claim is an exact match of any of the hospice claim’s diagnosis codes.
While this edit is new, it is longstanding Medicare policy that - relative to hospice patients - Medicare only pays separately for hospital inpatient services when those services are not related to the treatment of the terminal condition for which hospice care was elected (Medicare Claims Processing Manual, Chapter 11, Section 50).
If the hospital inpatient services are related to hospice services, CMS considers any payments to the hospital to be overpayments.
The implementation date of the CR is April 7, 2014. However, the CR instructs MACs to retroactively review hospital claims with dates of service within three years of the implementation date. As such, MACs are expected to recoup the overpayments from the billing hospital for any hospital claims that match the edit criteria.
Hospices are advised that hospitals may then seek payment from the hospice.
The National Association for Home Care & Hospice (NAHC) and its affiliate, the Hospice Association of America (HAA), suggest hospices do the following:
Review hospital contract language to ensure it addresses the billing procedures between the hospice and the hospital
Review patient consent forms to ensure they address situations where the patient seeks treatment for related conditions that is outside the hospice plan of care and/or does not go through the hospice to arrange the treatment
Review patient admission paperwork to ensure it includes information on hospitals contracted with the hospice for inpatient services and the need for the patient to go through the hospice to arrange care and only utilize the contracted hospital for hospice-related inpatient care