When a Hospice Patient Comes to the Hospital
By Tiffany Ferguson, LMSW, CMAC, ACM, FCM
A recent question was posed related to “What happens when a hospice enrolled patient returns to the hospital for emergency or hospital care?”
Aside from the initial questions such as “did we even know this patient was on hospice when they roll through the emergency room, or why did they come back to the hospital? The next question may evolve to the following: is the treatment still involving care congruent with the patient’s hospice care plan or has the patient/representative elected to revoke their hospice services?“
Understanding these distinctions is increasingly important for case management, utilization review, registration, revenue cycle, and especially hospital clinical teams. Particularly with the publication here last week of my article on Advance Care Planning.
The Medicare rules are more specific than many hospital workflows suggest. For reference, under the Centers for Medicare & Medicaid Services (CMS) requirements, an individual must be entitled to Medicare Part A and certified as terminally ill to elect the Medicare hospice benefit.
CMS defines terminal illness as a medical prognosis that the individual’s life expectancy is six months or less if the illness runs its normal course. The beneficiary or authorized representative must then elect hospice with a particular Medicare-certified hospice agency.
During a hospice election, CMS states that the beneficiary waives Medicare payment for services related to treatment of the terminal illness and related conditions, with limited exceptions. Those services remain covered when they are furnished by the following:
The designated hospice, either directly or under arrangement;
Another hospice under arrangements made by the designated hospice; or
The beneficiary’s designated attending physician, subject to CMS requirements.
The patient’s hospice election remains in effect until it is terminated through an allowable process, such as revocation or discharge from hospice. Therefore, when a hospice patient arrives at a hospital for a condition potentially related to the terminal illness, communication with the designated hospice is important for determining the patient’s status with their hospice services, the treatment plan, and who is financially responsible for the hospitalization.
Services for conditions completely unrelated to the terminal illness and related conditions can remain covered under Medicare. CMS, however, advises that this should be rare and unusual.
Revoking Hospice
If the patient is receiving services related to their treatment, typically a change in the goals of care back to aggressive treatment, this would require formal hospice revocation. CMS states that an individual or authorized representative may revoke hospice at any time. However, the hospice itself cannot revoke the beneficiary’s election. Revocation must be made in writing. The beneficiary must file a document with the hospice that includes a signed statement revoking their hospice election and the effective date of this revocation. CMS states that this cannot be made verbally or retroactive, and it must come from the patient and/or representative, not the hospice agency.
Once hospice is revoked, the beneficiary is no longer covered under the Medicare hospice benefit for the remainder of that election period and resumes Medicare coverage of the benefits that had been waived through the hospice election. Consider a beneficiary who remains enrolled in hospice when admitted to the hospital on Aug. 8 and subsequently signs a hospice revocation effective Aug. 10.
The revocation cannot be made retroactive to Aug. 8. This demonstrates why the hospital should have this form on file, when billing occurs. As the hospital would bill the hospice for Aug. 8 and 9 services, while starting Aug. 10, Medicare Part A would assume financial responsibility.
There is an additional layer when the beneficiary is enrolled in a Medicare Advantage plan. During the hospice election, coverage for hospice-related services reverts to Traditional Medicare. According to CMS guidelines, if a Medicare Advantage beneficiary revokes hospice or is discharged alive, Traditional Medicare continues to provide coverage through the end of that calendar month.
Medicare Advantage coverage resumes on the first day of the following month.
An Example: Hospice Revocation
Hospice revocation is effective Monday, Aug. 10, from the ED and time of admission. The patient is discharged home on Tuesday, Aug. 18. Traditional Medicare remains responsible for Medicare coverage through August 31. Medicare Advantage billing and coverage resumes Sept. 1.
In summary, the central concept is that hospice is an election of a Medicare benefit. During the hospice election, the beneficiary waives Medicare payment for services related to the terminal illness and related conditions, except as permitted under the hospice benefit. A hospital presentation does not automatically terminate the hospice election.
Revocation requires written action by the beneficiary or authorized representative. It cannot be initiated by the hospice or applied retroactively.
For Medicare Advantage beneficiaries, the transition following hospice revocation requires additional consideration. Traditional Medicare coverage continues through the end of the calendar month in which hospice is revoked. Medicare Advantage coverage resumes on the first day of the following month. Understanding these requirements helps hospitals identify the appropriate payer, coordinate services with the hospice agency, and apply Medicare requirements correctly when hospice-enrolled patients require hospital care.