Wednesday, February 2, 2011

Federal Government Wants to Tighten Hospice Admissions. Why?

The Affordable Care Act of 2010 (ACA),  Pub. L. 111-148, enacted March 23, 2010 (aka Obama Care) includes a section that applies to the terminally ill.

The problem from the perspective of the federal government is that the terminally ill in hospice care are living beyond the expected 6 month period.

Instead of analyzing what aspects of the hospice care experience are extending the lives of terminally ill patients, our federal government (in its infinite wisdom) chooses to create yet another burden for the medical practitioner.

Face-to-face requirements in several care settings have been established through the Affordable Care Act (ACA).  The actual face to face requirement is designed to reduce fraud, waste, and abuse by assuring that physicians and other medical care providers have met with the terminally ill to ascertain their specific health care needs.  

I understand that fraud exists in the Medicare system.  But it is absolutely insulting to suggest that a physician would falsify a hospice certification.  It is more likely that the terminally ill patient is receiving less aggressive care in hospice care.  Perhaps the less aggressive care has brought peace to the patient.

Medical care providers are reasonably concerned that the rules may in fact delay care for the patient.  Patient advocates must maintain communication with the medical provider's office in order to assure timely access to necessary services. 

When the hospice face-to-face requirements become effective, a hospice physician or hospice nurse practitioner must:
have a face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3rd benefit period, no more than 30 calendar days prior to the 3rd benefit period recertification, and must have a face-to-face encounter with that patient no more than 30 calendar days prior to every recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.[42 C.F.R. §418.22(a)(4)]
The required narrative of certification must include a statement, written directly above the physician's signature, attesting that the physician confirms that the narrative is based on his or her examination of the patient.[14]  In addition, the narrative for the 3rd benefit period and each subsequent benefit period must explain why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.[42 C.F.R.42 C.F.R. §418.22(b)(3)(iii)]
The certification of the physician or nurse practitioner who performs the face-to-face encounter must contain a written attestation that he or she had the face-to-face encounter with the patient.[42 C.F.R. 42 C.F.R. §418.22(b)(3)(v)]  The certification must be in writing; and must be a separate and distinct section or an addendum to the recertification form; and must be clearly titled.  If done by a nurse practitioner, the nurse practitioner must state that his or her clinical findings from the face-to-face encounter were provided to the certifying physician. [42 C.F.R. 42 C.F.R. §418.22(b)(4)]  Moreover, all certifications and recertifications must be signed and dated by the physician(s), including the benefit periods to which the certification or recertification applies.[42 C.F.R. 42 C.F.R. §418.22(b)(5)]

At this point, the face to face meeting requirements have been postponed. 

Sent: Thu Dec 23 13:46:42 2010 
Subject: Hill Notification: Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for Home Health Certification and Hospice Recertification
U.S. House and Senate Notification December 23, 2010
To: Congressional Health Staff
From: Amy Hall Director, Office of Legislation Centers for Medicare & Medicaid Services
Re: Additional Time to Establish Protocols for Newly Required Face‐to‐Face Encounters for Home Health Certification and Hospice Recertification
Due to concerns that some providers may need additional time to establish operational protocols necessary to comply with face‐to‐face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, the Centers for Medicare & Medicaid Services (CMS) will expect full compliance with the requirements, beginning with the second quarter of CY2011.
Section 6407 of the ACA established a face‐to‐face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non‐ physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.
Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face‐to‐ face encounter with a hospice patient prior to the patient’s 180th‐day recertification, and each subsequent recertification. The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period. The provision applies to recertifications on and after January 1, 2011.
Although many hospices, home health agencies and physicians are aware of and are able to comply with this policy, CMS is concerned that some may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, home health agencies and physicians who order home health services will collaborate and establish internal processes to ensure compliance. Likewise, CMS also expects hospices to establish internal processes during the first quarter. Beginning with the second quarter, CMS will expect home health agencies and hospices to have fully established such internal processes and have appropriate documentation of required encounters.
CMS will continue to address industry questions concerning the new requirements, and will update information on our Web site at and CMS and its contractors will also use other communication channels to ensure that the provider community is properly informed of this delay.
If you have any questions about this announcement, please contact the CMS Office of Legislation.
42 C.F.R. §418.22(a)(4)

Caregivers should read about hospice programs and try to implement aspects of hospice care in the home environment.

Regardless of the the seriousness of your patient's illness (simple cold, broken leg or cancer), strive to create an environment of peace, flexibility and compassion. 

J Indian Med Assoc. 2001 Dec;99(12):687-8, 690-1, 709.
The concept of hospice in theory and practice.

Center for Medicare Advocacy

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