How physician services are billed under Hospice

[Tomswife]

There is a thread under the Current Caregivers - Hospice Pros and Cons.

This thread is about billing. Medical care is a business. If you are in Hospice care, the services are billed under original Medicare and paid 100 percent.

You don't need to be end stage of a disease to use Hospice. You need to have a terminal illness and forgo curative treatments, related to that disease. You can be on Hospice for 6 months. Go off and go back on. My PALS is no longer on curative treatments. And, he is late but not end stage.

What if...you want to be on Hospice and also use your physician specialists? Can you see your pulmonologist? Gastrointerologist? How would they get paid? If the hospice doctor is to consult with your PCP, how does the PCP get paid?

To add complexity, our system Summit Health is built on a network of specialists. Hospice told me they can reach out to our PCP for consultation. But that isnt how our Summit Health care system works. We have a terrific PCP, and he refers to the neurologist, pulmonologist, Gastrointestinal physician. Etc. OUR PCP is not going to treat complex issues better served by a specialist.

I think we need to understand the financial aspects of PALS care if we choose Hospice and I dont fully understand this yet. The attached document was helpful.

And, not surprisingly, the document tells a different story than the one I was told by the Hospice nurse. I knew I had to get to how services get billed. That is the real story.

 

[lgelb]

Some possibly helpful working assumptions for those on Medicare of any flavor include:

You will not pay for hospice staff (on the payroll) services if hospice has been duly ordered by an in-network provider.

You cannot presume anyone at hospice will consult with anyone outside hospice or vice versa, or that drug interactions between anything hospice gives you and anything you are already taking will be identified or monitored. There is a greater chance of shared records/coordination if your existing provider system or a sister entity owns or operates the hospice.

Different hospice agencies can view palliative meds like benzos and morphine very differently for different conditions/patient locations/visit frequencies. Don't make any assumptions about your medication management based on anything you read here or hear elsewhere.

As always, you can seek palliative meds from a provider apart from hospice, though I wouldn't leave them all on the kitchen counter. However, your PCP is the least likely to prescribe any if you are actually on hospice.

Apart from ALS treatment per se, you can still go anywhere your plan permits for care presuming there's another dx code besides ALS that applies to you, but divulging or their seeing in the portal that you are on hospice may affect their zest for ordering tests/the aggressiveness of the treatment plan.

In ALS, hospice recertification should the need continue past the initial certification, should be routine. If any agency intimates it's not, they'd be off my list.

 

[lynnbr2]

Hospice requires that you sever your relationships with your previous doctors, all of them. The Hospice Group has a physician. That is your new doctor for everything.
Hospice Care Coverage
You can drop Hospice, see your old docs, then reenroll in hospice or switch to home health.

 

[lgelb]

Read that page more closely. ALS is a bit different, most PALS (none, I hope!) are not relying on Original Medicare or an HMO design for their blood pressure meds, etc. You can't go to the ALS clinic any more but it's not like cancer where you stop chemo. All else is up for grabs. If you get an ex post facto denial (no one can keep you from seeing your pulmo, etc.), you can appeal it. I have never heard of that, however. The major MA carriers all know what ALS is and it is case-managed for claims adjudication, even under hospice.

Yes, the page tries to discourage utilization outside hospice because they don't want to pay, but that has nothing to do with how the claim is processed when you do go. And again, it is not written for ALS at all. The bulk of hospice patients are cancer, COPD, CRF, and/or CHF.