After a recently completed investigation, the Office of the Inspector General (OIG) has issued a report entitled “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice.” This report draws attention to the fact that hospices may not be paying appropriately for their patients’ medications.
Hospice care is a Medicare Part A benefit. To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of Medicare and be certified as terminally ill (i.e., having a life expectancy of 6 months or less). The Medicare hospice benefit includes a per diem payment made by the Centers for Medicare & Medicaid Services (CMS) to a hospice organization for each day that a beneficiary is in hospice care, regardless of the number of services furnished. Drugs used primarily for symptom control and the relief of pain related to the individual’s terminal illness are covered under the hospice benefit, and the cost of providing these drugs is included in the per diem rate. As a result, hospice organizations should pay the dispensing pharmacies for these drugs.
Medications NOT related to the patient’s terminal diagnosis or to general end-of-life symptom management are paid for by the patient’s Medicare Part D benefit, another private insurance plan, or out-of-pocket by the patient themselves. But what the OIG has found is that Medicare Part D has been paying for medications that should have been paid for by the hospice, out of the per diem provided by CMS. In other words, the Medicare program paid twice for these medications. In addition, patients may have paid a copay that they shouldn’t have had to pay.
During calendar year 2009, the OIG identified 198,543 hospice beneficiaries who received 677,022 prescription drugs through the Medicare Part D program that potentially should have been covered under the per diem payments made to hospice organizations. These drugs were prescription analgesic, anti-nausea, laxative, and anti-anxiety drugs, as well as prescription drugs used to treat COPD and ALS. Medicare Part D paid pharmacies over $33 million for these prescription drugs, and beneficiaries paid nearly $4 million in copayments.
In response to these findings, the OIG has made a number of recommendations to CMS. The OIG recommends that CMS:
• educate hospices, pharmacies and Medicare Part D sponsors that Medicare Part D should NOT pay for drugs related to a hospice patient’s terminal illness
• perform oversight to ensure that Part D is not paying for drugs that Medicare has already covered under the per diem payments made to hospice organizations
• require Medicare Part D sponsors to develop controls that prevent Part D from paying for drugs that are already covered under the per diem payments.
What might this report mean for your hospice? The government has already been cracking down on hospices due to increasing reports of Medicare fraud, and with this new alert issued by the OIG, it is likely that these investigations will continue, if not increase in frequency. It is extremely important that hospices make the correct determination regarding which of a patient’s medications to cover, and that they document the rationale behind each coverage decision made. Once coverage decisions have been made, the hospice should have procedures in place to assure that billing is happening properly, so that medications are not inadvertently being paid for twice.
The decision of whether to pay for a particular medication is often a complicated one. We have guidelines that may help. In the last two editions of the Outcome Resources drug information newsletter, The Clinician, we have reviewed, in a two-part series, our Guidelines for Covered Medications in Hospice Patients. These guidelines may help your hospice ensure that you are making the proper decisions regarding medication coverage for each of your hospice patients. If you don’t have a copy of the newsletter, please contact us to request one.
| July 10, 2011Oh, I love that picture. That may be my fartvioe.The human body does some miraculous things as we die, including giving us one last rally. This may be what your mom is doing. The last rally provides an opportunity for everyone to gather and share one last time.If I might make a suggestion: I believe your mom is ready. I think she felt better about leaving once Hospice became involved because she knew you would have help and support. I'm sure you've done this alreay But, just in case: If you could let her know that you're okay, that it's okay that she leaves, then you would truly be giving her an incredible gift. Hope this helps.
Posted 2/14/2013 12:26:56 PM
|COPD and Lung cancer are two distinct conditions, but they definitely are related. Most patients who have lung cancer also have COPD (estimates have been published that up to 80% of lung cancer patients also have COPD). It has been established that COPD raises the risk for Lung Cancer. The symptoms of Lung Cancer and COPD are very similar and overlap. Medicare regs require the hospice to cover drug therapy that is necessary for management of the terminal illness (in this case Lung Cancer) AND related conditions (in this case COPD). There is no question in my mind that Lung Cancer and COPD are related and therefore, the meds commonly used for management of COPD should be covered for the patient with a hospice diagnosis of Lung Cancer. You are right, Sonjia:: much education needs to occur.
-- Jim Joyner
Posted 7/24/2012 10:22:29 AM
Thanks for your question. I think the sentence you are referring to is this one: "Medications NOT related to the patientâ€™s terminal diagnosis or to general end-of-life symptom management are paid for by the patientâ€™s Medicare Part D benefit, another private insurance plan, or out-of-pocket by the patient themselves." I apologize if this was not clear. What I mean is that the hospice should pay for medications related to the terminal diagnosis or EOL symptom management; everything else should be paid for by Medicare Part D, private insurance, or the patient themselves. Medicare Part D should NOT be billed for medications related to general EOL symptom management.
I agree with you that education is a must. It's a very complicated issue and we get questions all the time regarding what should and should not be covered. Regarding your lung cancer/COPD question: I've seen hospices do both, and I think you could make a convincing argument not to cover long-standing COPD meds in a patient with newly diagnosed lung cancer. But in a patient with shortness of breath from lung cancer, I think you may have a hard time making the argument that the bronchodilators you are using for COPD are not providing symptom management for the lung cancer -- patients with lung cancer frequently end up using meds like inhaled bronchodilators and inhaled corticosteroids to manage their disease, so could you convince an auditor that the patient's albuterol is not related to the terminal diagnosis? In the OIG's report, COPD meds were one of the groups of medications identified as being frequently paid for by Medicare Part D when they should have been paid for by the hospice. I don't know what the patients' terminal diagnoses were in these cases, but I think the point is that there is significant confusion -- or differing opinions -- surrounding when and when not to cover inhaled medications.
Thanks again for your comments!
-- Julia Harder
Posted 7/24/2012 06:44:36 AM
|Much education needs to occur to get a clear understanding of this. I have heard both extremes - the medical director of a FI told me a few years ago that I should be covering eye drops for glaucoma for the dx of debility (I disagree) and a hospice told me hospice should only cover meds for pain, SOB, nausea, etc and never meds such as albuterol for COPD (I disagree again).
In your last issue, you stated that a pt with a hospice dx of lung cancer and who also has COPD should have their inhalers covered. If that pt has been using inhalers for years for COPD and now has lung cancer why would hospice cover them? They are unrelated diseases.
-- Sonjia Hauser
Posted 7/23/2012 01:48:49 PM
|I'm not sure what you mean when you state above that "general end of life symptom management" is covered by Part D. How would you distinguish that type of symptom management from that related to the terminal diagnosis? Can you please provide examples of general EOL symptom management that the hospice would not be responsible for? Thanks.
-- Terri Maxwell
Posted 7/20/2012 06:12:38 AM
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