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Posts from the ‘hospice’ Category

Feb 5

Hospice Meds and Medicare Part D

If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

Jan 18

8 Comments

Your Rights as a Provider

It is not my desire to create drama but then again, I am not the one who took away your rights as a provider.

Your contract with Medicare is simple.  It states that you are qualified to perform services for home health and hospice patients and Medicare will pay you according to an agreed schedule.  Occasionally, they review clinical records and refuse to pay based on their assessment of your chart.  If you agree with their decision as is sometimes appropriate, so be it.  If you feel as though you disagree with their decision, you can appeal.

Sort of…..

Last week, I heard a rumor started by the National Association of Home Care and Hospice that the ALJ’s weren’t going to be docketing any more cases from home health and hospice providers.  I knew this could not be the case so I emailed Mr. Dombi at NAHC and he responded by sending a scanned copy of a letter from the Chief Administrative Law Judge, Nancy Griswold confirming this complete and utter lunacy.

For those of you who do not work in the world of appeals and do more important things like take care of sick people in their homes, let me explain this to you.

Imagine you did something else for a living.  Humour me and pretend that you are a roofer.  My insurance company who supplies 95 percent of your business  agreed to pay you to put a roof on my house and you did a fine job.   You shingled my home with materials that will withstand a category 5 hurricane and then you sent a bill and my insurance company politely declined to pay it.   Since the services were covered under your contract, the advance Roof Recipient Notice won’t protect you and I am held harmless while enjoying the sound of the rain on my new Cat 5 roof.

You take your complaint to the board of insurance and they tell you that you are right!  You did install at Cat 5 roof on my house but it doesn’t matter.  No payment is forthcoming.  Their reasoning is that in order to begin work, they had you sign a 30 page contract and on page 27, halfway down, it said that in order to be paid, you must initial the bottom of every page of the contract.  You only initialed 15 pages.

You decide the whole world of roofers and contractors has gone crazy and decide to take the insurance company to court.  The problem is there is no judge to hear your case.

So, I get the roof.  You get nothing and you have no rights.  The insurance company who signed a contract agreeing to pay you is sitting pretty with another satisfied customer under a Cat 5 roof and all you can do is work harder and faster to make up for the lost dollars.

That is exactly what is happening with Medicare appeals right now.  Payment is being refused for up to half of all claims at some MACs (e.g. Palmetto GBA, NGS, CGS) and you do not have any right to appeal denials past a certain point.  There is no person that you can talk to and you are completely unsure if anyone is actually looking at your records before rubber stamping  ‘denied’ on your claim. In short, they don’t give a flying flip that you had to pay your nurses or cover supplies.

When I work appeals, most of my work is done with the ALJ in mind.  If it’s good enough for them, it should satisfy the lower levels of appeals but often it does not.  The ALJ is the first human being that you can plead with to be reasonable. Except in desperate and extreme cases, the appeals process ends there.

Ms. Griswold confidently speaks to the increase in the number of denials being appealed but she does not speak at all to the increase in denials that are fully appealable or the rate of denials being overturned by Administrative Law Judges for the first two levels of appeal.   If the first two levels of appeals were performed competently, the workload at the ALJ would naturally fall as a byproduct of efficient, ethical and fair clinical reviews.

She makes a very valid point that the number of cases has increased overwhelming the ALJ’s but instead of addressing the huge percentage of denials that should have never been, she asks for ‘indulgence’.  It’s like pouring salt into a wound.

How dare Ms. Griswold ask for indulgence when almost half of the claims for home health have been denied by some MACs for grammatical errors relating to the F2F encounter documentation?   She wants to thank us in advance even though she has the responsibility to be well aware that her staff is ultimately overwhelmed due to the enormous increase in unfair denials.

I beg for your indulgence when I say that someone in Washington, starting with Ms. Griswold needs to have the courage to stand up for the good providers and quit playing political games with the healthcare needs of our elderly.

According to the HHS website, Ms. Griswold can be reached at:

OMHA Headquarters
1700 N. Moore St., Suite 1800
Arlington, VA 22209

Phone: 703-235-0635;   Fax: 703-235-0700

E-mail: Medicare.Appeals@hhs.gov

Make use of this information.  If you don’t speak up now, you may not be able to later.

Thanks to NAHC for sharing this information freely without regard to membership status. The content and sentiment in this post are mine alone and should not be attributed to NAHC or any other entity or person. 

Dec 29

11 Comments

Louisiana Hospice

Bobby Jindal, Governor of Louisiana.

Bobby Jindal, Governor of Louisiana.

“You can judge the character of a man by how he treats those who can do nothing for him”.   Malcolm Forbes

The source of the above referenced quote is debatable and has been credited to Ann Landers, Goethe, and numerous others.  It really doesn’t matter.   I cannot think of a single decent person who has not treated those who can nothing for him with respect and dignity.

Louisiana, known for food, fun, Mardi Gras and large close knit families has been let down by our Governor and the Department of Health and Hospitals.  I am deeply saddened and ashamed by our elected governor and his appointed head of DHH, Bruce Greenstein.

Effective February 1, 2013, Louisiana Medicaid will no longer pay for hospice.  Patients with Medicare will continue to receive benefits but those who depend upon Medicaid alone will no longer receive care in their homes or hospice care delivered as an adjunct in a nursing home at the end of their life.

Those individuals that rely on Medicaid for hospice care as the sole payor source for their healthcare will be forced to choose between dying at home with loved ones ill equipped to manage their care or go to a sterile institution and be cared for by strangers.

Consider who these people are.  Gay men dying of HIV, IV drug users with failing livers and those people who haven’t been able to find or hold onto a job with benefits will suffer disproportionately.  Most addicts who have terminal illness have an underlying psychiatric disorder either diagnosed or undiscovered.  Society’s undesirables, the forgotten, and those who are financially burdensome because they don’t pay taxes will be overlooked by the state of Louisiana.

Lucky for the Governor, they will not be able to vote once they are dead.  They will not speak out because they can’t.  If they have families, they will be too exhausted from caring for a dying loved one to worry about politics.  In some ways, this was a politically savvy move for the governor.

What Jindal overlooked is that these financial burdens to society have value other than financial.  Of course, Jindal doesn’t recognize their contributions to society because they can do nothing for him.  The gay man with end stage HIV may have a family who loves him.  The IV drug abuser may be all that their spouse has.  The unemployed may have children who are losing a parent.  The disproportionate number of patients with mental  illness will hardly notice the absence of benefits.  They have long since been overlooked by the Jindal administration.

He drove home the cruelty of his decision by insisting that that the home health care benefit remained in effect for Medicaid patients.  Essentially this translates into home health care agencies taking on even more underpaid and unpaid care.  The 50 visits a year Medicaid paid at a rate of half of what Medicare pays allows for home health is often insufficient for non terminal patients.  The quota for a terminal patient can be exhausted in a month or less if the patient receives quality care.

Many agencies will provide the care at a sharp loss while Medicaid RACs scrutinize every visit note for an opportunity to take back the scant amount of money paid.

But these guys – the gays, the junkies and the bums who don’t work obviously do not merit good care in Jindal’s opinion. They can do nothing for him.

If you agree with Jindal, I respect your right to your opinion but I do not care to hear it.  If you think that the state of Louisiana has implemented a reduction in Medicaid Benefits that is the equivalent of spitting in the faces of the needy and poor, please take the time out of your day to let The Secretary of DHH our governor know.

Bruce Greenstein, Secretary of Louisiana Department of Health and Hospitals is at:

Department of Health and Hospitals
P.O. Box 629
Baton Rouge, LA 70821-0629

The ‘contact us’ page on the Governor’s website has a variety of ways to contact him.  See below.  If you are a hospice or hospice association and are holding a public event soon, please consider asking B0bby to attend.

Choose one of the links below to interact with Governor Bobby Jindal:

    1. Email the Governor
    2. Request the Governor Attend an Event
    3. Request a Meeting with the Governor
    4. Request the Governor for a Photo
    5. Request a Proclamation from the Governor
    6. Request an Official Statement or Certificate from the Governor
    7. Apply to serve on a Board or Commission
    8. Nominate someone for the Governor’s Spirit of Louisiana Award

Sep 9

10 Comments

Blue Moments

This story was posted on Facebook by a friend and I looked around to see who wrote it.  Initially, it was written off as an urban legend with a Chicken Soup for the Soul twist.  As it turns out, it was originally written by a man named Kent Nerburn in his book, Make Me an Instrument of Your Peace.  He calls these moments ‘Blue Moments’ where brilliant light shines through through the ordinary moments in our ordinary days.

A NYC Taxi driver wrote:

I arrived at the address and honked the horn. After waiting a few minutes I honked again. Since this was going to be my last ride of my shift I thought about just driving away, but instead I put the car in park and walked up to the door and knocked.. ‘Just a minute’, answered a frail, elderly voice. I could hear something being dragged across the floor.

After a long pause, the door opened. A small woman in her 90’s stood before me. She was wearing a print dress and a pillbox hat with a veil pinned on it, like somebody out of a 1940’s movie. By her side was a small nylon suitcase. The apartment looked as if no one had lived in it for years. All the furniture was covered with sheets.  There were no clocks on the walls, no knickknacks or utensils on the counters. In the corner was a cardboard box filled with photos and glassware.

‘Would you carry my bag out to the car?’ she said. I took the suitcase to the cab, then returned to assist the woman. She took my arm and we walked slowly toward the curb.  She kept thanking me for my kindness.

‘It’s nothing’, I told her.. ‘I just try to treat my passengers the way I would want my mother to be treated.’

‘Oh, you’re such a good boy, she said. When we got in the cab, she gave me an address and then asked, ‘Could you drive through downtown?’

‘It’s not the shortest way,’ I answered quickly..

‘Oh, I don’t mind,’ she said. ‘I’m in no hurry. I’m on my way to a hospice.
I looked in the rear-view mirror. Her eyes were glistening. ‘I don’t have any family left,’ she continued in a soft voice..’The doctor says I don’t have very long.’ I quietly reached over and shut off the meter.

‘What route would you like me to take?’ I asked.

For the next two hours, we drove through the city. She showed me the building where she had once worked as an elevator operator.  We drove through the neighborhood where she and her husband had lived when they were newlyweds She had me pull up in front of a furniture warehouse that had once been a ballroom where she had gone dancing as a girl.

Sometimes she’d ask me to slow in front of a particular building or corner and would sit staring into the darkness, saying nothing.  As the first hint of sun was creasing the horizon, she suddenly said, ‘I’m tired.Let’s go now’.

We drove in silence to the address she had given me. It was a low building, like a small convalescent home, with a driveway that passed under a portico.  Two orderlies came out to the cab as soon as we pulled up. They were solicitous and intent, watching her every move.  They must have been expecting her.
I opened the trunk and took the small suitcase to the door. The woman was already seated in a wheelchair.

‘How much do I owe you?’ She asked, reaching into her purse.

‘Nothing,’ I said
‘You have to make a living,’ she answered.

‘There are other passengers,’ I responded.

Almost without thinking, I bent and gave her a hug.She held onto me tightly.
‘You gave an old woman a little moment of joy,’ she said. ‘Thank you.’  I squeezed her hand, and then walked into the dim morning light.. Behind me, a door shut.It was the sound of the closing of a life..

I didn’t pick up any more passengers that shift. I drove aimlessly lost in thought. For the rest of that day,I could hardly talk.What if that woman had gotten an angry driver,or one who was impatient to end his shift? What if I had refused to take the run, or had honked once, then driven away?

On a quick review, I don’t think that I have done anything more important in my life.

We’re conditioned to think that our lives revolve around great moments.
But great moments often catch us unaware-beautifully wrapped in what others may consider a small one.

Apr 30

1 Comment

Thanks, HEALTHCAREfirst!

Bobby, Deanna and Meghan
Making it Happen at HEALTHCAREfirst

Now would be a good time to offer my sincerest gratitude to my hosts last week at the HEALTHCAREfirst Conference.  I learned a lot of interesting things and met some really cool people.  The most fascinating thing that I learned is where all the Healthcare First Data is stored.  If you use Healthcare First software, you may not want to know the answer so I will leave that alone for now.

Although data storage is fascinating to be sure, I have never grown tired of hanging out with home health professionals.  I learn more from y’all than anyone will ever learn from Haydel Consulting Services.  Since I came home to a ZPIC requiring my attention, let me just briefly highlight some of the things I learned.

  1. The easiest way to protect yourself from Medical Review is to ensure that your zip code is not in Chicago.
  2. There are agencies – read carefully, Louisiana clients – that actually have average lengths of stay close to 30 days for Medicare patients.
  3. I don’t think there is a perfect place for the driving involved in home health.  Did you know that there are agencies who pay for nurses to have chains put on their tires?
  4. Hospice providers may feel a little left out at times.  I guess that is why they are receiving ADRs and other regulatory audits, at an alarming rate.  PGBA, et al, did not want them to feel neglected.
  5. The Hard Rock Café in San Antonio is a great place to watch a parade during Fiesta.

More than ever, agencies are finding their revenue vulnerable as the result of extensive and robust (that’s a computer word) regulatory review by our Payor Source.  HEALTHCAREfirst is stepping up to the plate to assist agencies in maintaining the integrity of their data.  This is a good thing for the majority of providers who want to do more than simply survive in the upcoming years of uncertainty.  But I caution you,HEALTHCAREfirst and all of their competitors sell software.  You can push any button you want on the finest computer in the world and you won’t get nursing judgment or compassion to jump out of your machine.

Having said that, a cocktail of good solid data, strong leadership and intelligent, creative nurses is a plan for an agency that will enjoy financial and clinical outcomes long after this period of scrutiny settles .

So, I learned a lot and more importantly, I met some great people.  It is really fun to meet a stranger who understands exactly what I do for a living and shares my love of the home health industry (inclusive of hospice, of course).  My own family isn’t really sure what exactly I do for a living and I am not sure that anyone who isn’t on the playing field really knows how the game is played.  So, it was fun meeting everyone and if I promised to call and you haven’t heard from me, please send an email.  I have your card under a ZPIC letter so don’t take a chance on it getting lost!

Thanks to HEALTHCAREfirst and thanks to all of their clients who made San Antonio a really fun place to hang out for a few days last week.

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