Revoking and Hospitalization

[Kabin]

What's the norm for home hospice pt's going to the hospital for something related to the terminal diagnosis? It seems complicated. Sometimes it's unfair for the hospice agency to cover hospitalization costs and other times it borders on being unfair to the taxpayer.

What does you company do when a terminally diagnosed COPD pt decides to go to the hospital for COPD exacerbation?

I've seen cases were the MPOA/pt signs the revocation form that day and other times wait until the hospitalization is over and then have MPOA/pt sign the revoke form with a back date prior to the hospital admit date. What's acceptable?

Are there online US government guidelines for these scenarios?

[Kabin]

The power is suppose to be on the patient's side within reason of choosing hospice versus aggressive treatments.

• Once a hospice chooses to admit a Medicare beneficiary, it may not automatically or routinely discharge the beneficiary at its discretion, even if the care promises to be costly or inconvenient, or the State allows for discharge under State requirements. The election of the hospice benefit is the beneficiary’s choice rather than the hospice’s choice, and the hospice cannot revoke the beneficiary’s election. Neither should the hospice request or demand that the patient revoke his/her election.
  

Revocation of the Hospice Medicare Benefit | National Hospice and Palliative Care Organization

[FLArn]

However, if the patient has not revoked hospice, the hospital may not be able to bill Medicare for their treatment of the patient's exacerbation of the terminal diagnosis as Medicare will not pay for both aggressive and hospice care for the same diagnosis. Somebody isn't getting paid, and if it ends up being the hospital they may bill the patient/family. The hospice will inform the hospital that the hospice is not responsible financially since the treatment being provided by the hospital is outside the hospice plan of care. At least that is my understanding of how the hospice election reads.

[Kabin]

Sometimes, in the case of not revoking, the hospice agency picks up the hospital tab. Of course the hospice agency negotiates a nicely discounted rate with the hospital.

[TammyG]

The hospice has the choice of either paying the hospital bill or asking the patient to revoke. There are times with small hospitalization bills that we do not revoke. Or, if the patient is charity care funds we do not revoke, but then we expect the hospital to use their charity care funds to cover the bill.

[NC29mom, ASN, LPN, RN]

BACKDATING a revocation form is MEDICARE FRAUD

[Kabin]

It's interesting you say that cause that's what I was getting at! It seems like a red flag but I'm trying to picture how else it could be done. Until hospital treatments are decided there's really little way of knowing if and when the hospice agency should ask the pt/family to revoke.

I can't find guidelines online. How do your hospice agencies do it? Do they make the decision prior to hospitalization or absorb the costs?

[goldberryRN]

Our hospice would tell pt's/families that they could revoke in order to seek aggressive treatment for the hospice diagnosis, and as far as I know they always complied.

[NC29mom, ASN, LPN, RN]

It's interesting you say that cause that's what I was getting at! It seems like a red flag but I'm trying to picture how else it could be done. Until hospital treatments are decided there's really little way of knowing if and when the hospice agency should ask the pt/family to revoke.

I can't find guidelines online. How do your hospice agencies do it? Do they make the decision prior to hospitalization or absorb the costs?

We have one of our nurses on stand by at hospital so when decisions are made r/t tests/treatment a decision regarding revocation can be made immediately.

[makeitwork, BSN, RN]

I have to ask if the pt called the on-call nurse prior to going to the hospital. If they did not call us first, we did not have the opportunity to provide crisis care and, therefore, the pt is liable. As mentioned above, revocation would result in Medicare paying (outside of hospice). If we are called and our nurse is unable to provide symptom relief, we then take the responsibility for billing after sending the pt to the hospital. (I hope that made sense)

[Kabin]

Thanks for the input. It's complicated with many different company procedures.

I did a quick Google and saw a couple references to backdating being a no-no. I guess that makes sense.

[toomuchbaloney]

Typically speaking, hospices cannot require a patient or family to revoke the hospice benefit.

However, the hospice must inform the patient/family that the hospice is only obligated to pay for care that is included in the plan of care as determined by collaboration between the patient/family, Medical Director or managing MD, and the RN case manager. If the patient/family chooses care outside of the hospice plan of care they MAY be responsible for the full cost of that care.

Some hospice agencies have language written into their election of benefit document which states that IF the patient seeks aggressive medical care in the ED or in the acute care setting for the hospice admitting and qualifying diagnosis they are considered to have revoked their hospice benefit effective date of such event. If that is the case it is imperative that this nuance be clearly and plainly explained to the patient/family at time of election of benefit. Revocations cannot be back dated.

Many hospices will dispatch either an RN or a MSW to the ED when they learn of the patients transfer to that facility. At that time the hospice professional assists the patient/family in determining the goals of care, assists the ED staff in developing a hospice appropriate plan of care, or assists the family in completing a revocation of the benefit.