Trends help hospice managers avoid the cap
Four key items contribute to financial woes
Every hospice is different with varying populations to serve, but an analysis of the reasons that 40% of the 99 hospices in Oklahoma served by Palmetto Government Benefit Administrators (GBA), a Medicare fiscal intermediary, hit the hospice cap shows four predominant reasons, says Greg Wood, LBSW, executive director of the Hospice of North Central Oklahoma in Ponca City and president of the Oklahoma Hospice Association:
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Premature admission to hospice.
Even if a patient has a terminal illness, there is a period of time that other health care services, such as home health, can meet the patient's needs, says Wood. Just because a physician signs an order that the patient has a terminal illness, hospice may not be the only option or even the best option, he points out.
"In some cases, a physician may state that a patient is terminally ill to qualify them for admission to hospice when the physician is an owner or financially tied to the hospice organization," says Wood. While this is not the case for many physicians and patients, it does raise the issue of enforcement and places the burden on the Centers for Medicare & Medicaid Services (CMS) to enforce the rules, he adds. -
Long length of stay.
A hospice often will have patients who live longer than others, so it is important that care is taken to ensure a mix of patients that will keep the aggregate number of days of care below the cap, Wood says. Achieving this mix requires careful review of the patient's needs upon admission and at any recertification point, he adds.
A hospice's patient base should reflect the community, says Jonathan Keyserling, JD, vice president of public policy and counsel for the National Hospice and Palliative Care Organization (NHPCO) "There should not be a disproportionate number of short-stay, midstay, or long-stay patients," he explains. "Hospice providers may need to redouble their efforts to attract short-stay patients." -
Inadequate discharge planning process.
Even patients with terminal illnesses may reach a point during their illness that they don't require hospice services, Wood says. Unfortunately, many hospices don't have discharge planning processes in place to make sure that these patients are referred to home health or other services if their disease is in remission or if the decline in their health has stopped, he says.
"I had a conversation with one hospice provider who told me that his hospice didn't believe in discharging Medicare beneficiaries because they've earned the benefit," Wood recounts. "I don't advocate abandoning patients, but if they can be well served by other providers, discharge them to those providers and readmit them to hospice when appropriate." -
Lack of knowledge regarding cap and financial performance.
Hospice managers must monitor their reimbursement levels to determine how close they are to reaching the cap, says Keyserling. "Providers should be monitoring their financial data on a monthly basis," he recommends.
If you do see that you are close to the cap or exceeding it at any point, be prepared to set aside some funds to be available for future repayment, suggests Wood. This will ensure that the hospice will not be harmed financially by a demand from CMS, he adds.
Another basic problem is the lack of knowledge about the cap itself, says Wood. "A hospice provider once admitted to being in business for 10 years and not knowing that there was a cap on Medicare payments," he says. "Although it is only one little paragraph in the conditions of participation, it was also one of the first things I was taught when I was hired to run a hospice."
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