http://www.medicareadvocacy.org/FAQ_Hospice.htm

A QUICK SCREEN TO AID IN IDENTIFYING COVERABLE CASES

Medicare claims for hospice care are suitable for coverage, and appeal if they are denied, if they meet the following criteria:

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The patient is terminally ill and has elected Medicare hospice coverage. Patients are entitled to two 90-day election periods, followed by an unlimited number of 60-day periods.
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The attending physician (if one exists) and the medical director or physician member of the hospice interdisciplinary team must have certified in writing at the beginning of the first 90-day period that the patient was terminally ill. For all subsequent election periods, only a hospice physician must certify that the patient is terminally ill.
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The patient or his or her representative has signed and filed a hospice election form with the hospice of choice.
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The hospice provider is Medicare-certified.
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The services for which Medicare coverage has been denied were provided for the palliation and management of the terminal illness.

ADVOCACY TIPS:

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The attending physician is always the key to obtaining Medicare coverage. Obtain a statement from the beneficiary’s physician stating that the patient is terminally ill, that the services are reasonable and necessary for the comfort and management of a terminal illness, and that the services were included in the written plan of care.
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The beneficiary does not have to have cancer to qualify for the Medicare hospice benefit.
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The beneficiary does not have to have a "do not resuscitate order" to qualify for the Medicare hospice benefit.
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The beneficiary does not have to be homebound, and may go out as long as he or she is able to do so.
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If coverage is sought for inpatient services, in a hospital or skilled nursing facility, the physician should explain why the inpatient care was reasonable and necessary and that the care could not be provided in other than an inpatient setting.

WHAT IS HOSPICE CARE?

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Hospice care is compassionate end-of-life care that includes medical and supportive services intended to provide comfort to individuals who are terminally ill. Care is provided by a team.
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Often referred to as “palliative care,” hospice care aims to manage the patient’s illness and pain, but does not treat the underlying terminal illness.
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Hospice care may include spiritual and emotional services for the patient, and respite care for the family.
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Hospice care is provided by a team of appropriate professionals.
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Many hospitals and skilled nursing facilities have hospice units, but most hospice care is provided at home.
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Hospice Care Goals include ensuring that the patient will:
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Be as comfortable and pain-free as possible.
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Be independent for as long as possible.
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Receive care from family and friends.
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Receive support through the stages of dying.
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Die with dignity.

WHAT KINDS OF CARE DOES MEDICARE HOSPICE CARE INCLUDE?

Generally, hospice care includes services which are reasonable and necessary for the comfort and management of a terminal illness. These services may include:

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Physician services.
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Nursing care.
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Physical therapy, occupational therapy, and speech-language pathology services.
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Medical social services.
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Hospice aide services.
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Homemaker services.
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Medical supplies, including drugs and biologicals and medical appliances.
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Counseling, including dietary counseling, counseling about care of the terminally ill patient, and bereavement counseling.
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Short term inpatient care for respite care, pain control, and symptom management.

WHEN WILL MEDICARE COVER HOSPICE CARE?

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A physician must certify that the beneficiary is terminally ill. This means that in the physician’s judgment the individual has 6 months or less to live if the illness runs its normal course.
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The beneficiary or his/her representative must elect the Medicare hospice benefit by signing and filing a hospice benefit election form with the hospice of choice.
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The beneficiary’s attending physician and the hospice physician must certify the beneficiary for the initial period. For subsequent periods the hospice physician recertifies the beneficiary.
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After having been certified by a physician, the beneficiary may elect the hospice benefit for two 90 day periods and an unlimited number of subsequent 60 day periods.
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All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, in accordance with the patient's needs if any of them so desire.
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The care must be provided by, or under arrangements with, a Medicare certified hospice.

HOSPICE MEDICARE APPEALS



Under Medicare, there are currently two methods of appeal available for denials of hospice care. The appeals are fraught with confusion and bureaucratic complications. To make matters worse, the two systems are not clearly named or demarcated. For purposes of this discussion, they will be referred to as "expedited appeals" and "standard appeals".



1. Expedited Appeals

The right to an expedited appeal became effective on July 1, 2005.[1] Hospice patients have the right to an expedited appeal when their provider decides to discontinue hospice care entirely.[2] The hospice provider must give the beneficiary a standardized "valid written notice" at least two days prior to the cessation of care.[3] Among other pieces of information, the standardized notice must tell the beneficiary the date that coverage of services ends; the date that the beneficiary's financial liability for continued services begins; and a description of the beneficiary's right to an expedited determination.[4] This notice is valid when the beneficiary (or the beneficiary's authorized representative) has signed and dated the notice to indicate that she has received the notice and can comprehend its contents.[5]

Providers are financially liable for continued services until two days after the beneficiary receives valid notice or until the service termination date specified on the notice, whichever is later.[6] A difficulty that often arises is that many agencies render both Medicare covered hospice and home health care. When beneficiaries are discharged from hospice care, they are often transferred to the agency's home health program. Providers sometimes inappropriately believe that since the beneficiary is still getting care from the same organization, they do not have to issue the standard notice regarding expedited appeal. If no notice is issued, the beneficiary will never know that she had a right to have the hospice program's discharge decision reviewed.

Another good article

http://www.hospicepatients.org/qa-emergency.html

Hospice Patients Alliance: Consumer Advocates


Hospice Patients Alliance
Emergency Answer Center
Hospice Emergency Answer Center

May the path you choose
bring peace and comfort
to your loved one!


There are many wonderful hospices in our nation, and there are many wonderful hospice staff serving the public who are extremely dedicated and caring. However, there is another side to health care: the following are actual questions commonly received here at the Hospice Patients Alliance. We provide these examples here so that perhaps you may find an answer to questions you may have about your situation. You can quickly scan the topics by scrolling down to find the red word: "Question."

In some cases, problems arise from simple errors in judgment, from ignorance or carelessness, and are unintentional. In other situations, greed may prevail over abiding by the standards of care and a hospice may choose to "cut corners," in certain situations (where they think they can get away with it) with devastating results to a patient or family here and there.

We don't believe that even the "rogue" hospices are "bad" all the time ... they may provide excellent hospice care to one patient and then provide either poor care to another patient in a particular type of situation or deny care altogether (in order to save or make money). The health care industry is in constant flux, always changing and evolving. While there is constant pressure to cut costs and services, the standards of care require decent, quality hospice care to be provided.

There is no one answer to the problems of health care or hospice care, but eliminating health care fraud would help...increasing funding for health care would help. Eliminating the "for-profit motive" out of health care decision-making would help. That is not to say that health care industries cannot make money; they should. But when top executives are getting millions of dollars salary and benefits per year and patients are denied basic care, something terribly wrong is happening.

Health care is a "calling" for the professionals that serve from their heart, in the field. Yet for some administrators in many agencies, it is solely a business that they happen to be working in. The charitable, non-profit motivation which started almost all great facilities in our nation needs to be strengthened in health care.

Large health care corporations complain about the cost of providing service, yet many make millions of dollars in profit, or pay administrators millions in salary and benefits. Pharmaceutical and durable medical equipment companies are extremely profitable. What happened to the heart of health care? What happened to the idea that we serve each other out of love, dedication, and the mission of health care? We hope that more of us will be motivated to start non-profit, charitable health care agencies, facilities and institutions where the public can be truly well-served!

We hope that you will find an answer that applies to your hospice emergency situation. If you don't find your answer here, check the main list of topics on our homepage and read the topic that seems to apply to your situation.




Question: My brother entered hospice after several months of battling lung cancer. He also has emphysema and suffered a stroke. When he entered hospice we had the understanding that occupational and physical therapy would be provided in an effort to keep him comfortable with the goal of trying to make him stronger.

Today, the occupational therapist came out and said that therapy is not generally permitted for hospice patients because Medicare frowns on providing therapy for what may very well be terminally ill patients.

This doesn't seem right. My brother has been feeling stronger day by day and wants to work at regaining some strength for as long as he's here with us. Is what the therapist said true? Can they simply deny my brother the therapy he wants and needs? Any help you can provide with this would be greatly appreciated.

Answer:

In hospice, everything done for your brother really is aimed at improving the quality of life he has while he is with you. Managing symptoms is part of hospice, but therapy is also a part of hospice if there is a possible gain to be made. If your brother had a stroke, how much mental function and physical ability does he still have? Certainly, you are correct that hospice must provide occupational therapy if it will increase the quality of life for your brother, even though he is terminal.

It is simply untrue to say that Medicare discourages hospices from providing therapy to hospice patients. In fact, the regulations require hospice to provide therapy if it meets the need of the patient and will improve the patient's quality of life! The regulation about hospice and therapy can be found posted on our website (and is part of the Code of Federal Regulations) at: 42 CFR ch. iv. section 418.92. Just find the section 418.92 which states:

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Sec. 418.92 Condition of participation--Physical therapy, occupational therapy, and speech-language pathology.

* (a) Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, offered in a manner consistent with accepted standards of practice.

Hospices are paid on a "per-diem" basis and get a lump sum of money per day. They are then required to provide whatever the patient reasonably needs to maintain or achieve comfort and help improve the quality of life as much as is realistically possible. Hospices can make more money (even nonprofits) by skimping on services. I don't know the exact condition of your brother, but if his physician determines that he would actually benefit from therapy, then the hospice must provide that service.

On the other hand, if your brother is truly weak and getting close to passing on, then doing the therapy could actually be almost "torture" for your brother. It really depends on his situation. Building up strength in the terminally ill is not always possible. If your brother were in remission, then that would be a worthy goal, but if he is at a late stage of the terminal illness, his metabolism may not be able to build up tissue/muscles etc. by absorbing the nutrients, processing them and creating new cells/tissue etc.

There is something called an "anabolic" state of metabolism and something else called a "catabolic" state of metabolism. If your brother is in serious metabolic decline, his metabolism would be catabolic and breaking down tissue, basically "falling apart" so to speak, or in other words: his organ systems may be failing.

The type of metabolism can be detected when the physician evaluates lab results, kidney function, etc. The anabolic state is the healthy state where our bodies are building up tissue and we are actively creating new tissues/cells, etc. All terminally ill will eventually end up in the catabolic state if they don't die of a sudden heart attack or pulmonary embolism or something like that.

So, to sum up, if in the physician's view, your brother has potential to benefit from the therapy, and your physician orders it, the hospice must provide that therapy. It would be helpful to speak with the physician and get an understanding of what your brother may accomplish in therapy. Then speak with the hospice RN case manager and work together to form a realistic plan that allows your brother to do therapy which he can tolerate and benefit from