Define your terms in an MCO contract
Here are some useful definitions
Ensuring clarity in a contract with a managed care company requires that both entities be speaking the same language. Here are some definitions it would be useful to have in your contract:
- Hospice: An organized program that provides palliative care to terminally patients and supportive service to patients, their families, and significant others in both home and facility-based settings. A 24-hour on-call service is available to evaluate the patient’s changing needs. The range and intensity of services will be consistent with those in the patient’s plan of care and approved by the health plan. Hospice services to be provided by the hospice will be in accordance with the patient’s individualized plan of care and include all the equipment, medication, treatment, and care required to manage the terminal illness of each health plan patient admitted to the hospice provider.
- Physician services: Physician services provided by the hospice will be limited to those associated with assisting in the coordination of the hospice program and those associated with the quality assurance and utilization review functions for the hospice program. Direct physician medical care is billed separately from the hospice per diem.
- Unrelated services, equipment, medication, treatment, and supplies: Items not related to the terminal condition and in the patient’s plan of care are not covered under the hospice benefit but may be covered under other benefit categories as stipulated by the plan.
- Palliative vs. curative: It is understood that hospice care is palliative rather than curative in treatment goals and treatment methods and that the definition of accepted palliative goals and methods is exclusively the province of hospice for all patients.
- Patient residence: A patient’s residence is a private home, nursing facility, intermediate care facility, group home, assisted living facility, licensed hospice facility, or other alternative residence.
- Routine hospice care: Intermittent scheduled care provided to hospice patients in their place of residence. A 24-hour on-call service is provided. As detailed in the patient’s care plan, services may include:
— physician-directed interdisciplinary case management focused on patient symptom control;
— services by licensed nurses, social workers, chaplains, counselors, nursing assistants, and volunteers;
— family counseling services to family members during the time the patient is receiving hospice care;
— bereavement care and counseling for family members for at least one year following the patient’s death;
— all interventions related to the terminal condition and necessary for the implementation of the patient’s plan of care, such as therapies, medications, and routine medical supplies.
The above definitions represent only a portion of the language that needs to be included in a managed care contract to make it hospice-specific. Other attachments address eligibility, fee schedules, and billing procedures.
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