Reimbursement/billing question

[Spidey's mom, ADN, BSN, RN]

Hello fellow hospice nurses. :)

I have a question that might seem pretty simple but I'm not savvy about the billing/reimbursement for hospice.

One of our patients has esophageal cancer. His pain was out of control and he had trouble swallowing. We ended up with a CADD-Pump of morphine sulfate however the insertion site would abcess every other day so for weeks we were back out there to find a new site every other day or so. This was costly - to our hospice (time and a half for the nurse) and for the patient (not very good pain control).

I mentioned a PICC Line at our IDT meeting - which we ended up getting for him at an outpt facility down the road.

He has attained great pain control and the PICC is working very well - no infection at all so far and it has been over a month.

Now the question - it cost $3000 to place that PICC and our hospice supposedly isn't getting reimbursed for that cost. So, we are going to pay for it out of donations.

I've been told by another hospice nurse that their facility does have PICC's and they are covered by insurance (Medicare, private insurance, etc).

What happens at your facility?

Thanks!

steph

[tewdles, RN]

I would imagine that the PICC placement expense could be covered under the insurance policy if the placement is required/recommended for a diagnosis which is different from the hospice diagnosis.

So, for instance, a cancer patient who requires IV antibiotics for pneumonia could, conceivably, have this insertion paid by insurance seperately from the hospice benefit. However, in the instance you used, IV access for purpose of providing symptom management for the hospice diagnosis is the financial responsibility of the hospice provider.

It is so much easier when our oncologic patients have implanted ports.

[Spidey's mom, ADN, BSN, RN]

thanks - another hospice nurse told me that her hospice does pay for PICC line placement - it is a reimbursable item.

I'm just frustrated by no one in MY hospice knowing the rules and regs . . . . and I'm new at that stuff.

So, we are paying for it out of donations.

steph

[heron, ASN, RN]

Hi, steph, glad you pointed me at this thread. I wish I could offer something concrete to help. Our hospice used to drop PICCs in a heartbeat, but I don't think we've placed one in our IPU in the last 4 years.

The tactic of seeing whether it's billable under non-hospice insurance seems the most promising. I know our company is trying to do this with non-related meds on our IPU to get costs down ... our billing company seems to be having trouble figuring it out, so the story's not over yet.

I have only the most rudimentary idea of how hospice is reimbursed, so it's hard to say what else would work. I'm surprised to hear that PICC placement is separately reimbursed at all ... I was under the impression that reimbursement was a flat fee based of level of service and that procedures had to be paid out of that.

Meanwhile, great work getting this one patient what he needed when he needed it. Glad it's working for him.

[Spidey's mom, ADN, BSN, RN]

I just think that is crazy . . . .to bill it under something non-hospice related.

Pain from the esophageal cancer, not able to swallow well without choking risk, abscess at SQ insertion sites with CADD Pump which means a nurse visit every day or two for a new site, antibiotic use for abscess, pain not well controlled, still has a ways to go before he actually DIES . . . shouldn't pain control be covered?

Thanks everyone for your thoughts - whatever the financial outcome, he is doing very well in regards to pain control now.

And that is the point. A peaceful and pain-free death.

steph

[heron, ASN, RN]

I just think that is crazy . . . .to bill it under something non-hospice related.

Pain from the esophageal cancer, not able to swallow well without choking risk, abscess at SQ insertion sites with CADD Pump which means a nurse visit every day or two for a new site, antibiotic use for abscess, pain not well controlled, still has a ways to go before he actually DIES . . . shouldn't pain control be covered?

Thanks everyone for your thoughts - whatever the financial outcome, he is doing very well in regards to pain control now.

And that is the point. A peaceful and pain-free death.

steph

The bolded question is perfectly legitimate. The question is, can hospice bill separately for the procedure. I suspect not ... that's not how the benefit was structured. It's more like a capitation plan (like an HMO).

As I understand it, the flat daily re-imbursement has to cover all meds, services, equipment and procedures. The theory is that, although costs for one particular patient may go above the re-imbursement for that particular patient, over time the company should be able to balance that out by keeping other patients' costs below the level of the reimbursement. The idea is to make the provider think long and hard about putting a patient through an expensive invasive procedure.

As I said, my understanding is only rudimentary ... hope someone who knows more can shed some light.

I can only imagine the intense talking, hard thinking and copious documentation that went into coming up with the solution you did ... again, good job!

[tewdles, RN]

You are correct that hospice is reimbursed on a "per diem" basis...that is, a daily "flat rate" is paid for each patient who has elected the hospice benefit (medicare). So NO procedure or treatment can be billed individually within the hospice POC. Only those things outside of the hospice primary diagnosis and POC could be considered for seperate reimbursement by Medicare.

That is precisely why not all hospices allow or encourage things like palliative radiation or chemo...they represent $$$ that the hospice must spend out of their per diem payments from Medicare. Beyond that, it can be difficult for hospice patients to get things like nerve blocks, PICC lines, or similar while on hospice if the agency providing their hospice care does not have the connections and cash flow to pay for them. When you hear of hospice patients who revoke, go to the hospital and then re-elect their hospice benefit...they may be cases of patients seeking payment for a procedure which hospice has declined to include on the POC...perhaps because of cost.

Excellent job getting that patient comfortable! Hospice nurses ROCK!