Revocations- how many is too many?

tencat · Mar 21, 2009

If the documentation supports keeping them on, then as far as I understand it they are eligible, even if it takes them YEARS (and I have had a couple of those) to die. Our doc once said about one of my long-timers "If he were to decline any further, he'd be dead at that point." Sometimes they take a while to go. And if they go into the hospital and seek treatment for their hospice diagnosis (ie: CHF goes in for fluid overload) the hospice is going to want to discharge the patient to avoid having to pay for the hospitalization. That's the only way medicare will pick up the bill for the hospitalization. I've had a couple that went through the 'revolving' door of being on service, then revoking, then coming back. They have to be ready to die, and a lot of the time they are not. So, these patients keep on going back to the hospital until they finally decide that enough is enough.

Debility is the tricky diagnosis. There have to be two or more life-threatening issues (diabetes and severe heart disease, for example) to bring them on. But once they're on, debility is a lot harder to qualify and justify for longer term service. I only have one debility right now, and he's on the edge of being revoked because it's a toss up as to what is going to get him first, if anything.

I don't totally understand how the whole reimbusement thing works, but if you are working for a for-profit company, they will try to keep as many patients as possible while minimizing as many costs as possible (kind of bugs me, but that's another thread). Hence, you get a lot of "hey, let's admit EVERYONE to hospice (until a medicare audit requires we pay back a million dollars)" or "Quick! Get rid of everyone because medicare is coming!" I have to fight tooth and nail sometimes to keep from admitting inappropriate patients because our powers that be just want the bodies and don't really care if they are 'medicare' appropriate or not. Usually I just mention that REALLY big fine we had a couple of years ago and they get it.

nursebitback · Mar 22, 2009

This was what I read that made me ask those questions:

Tencat!!! about 13 of our patients have General debility as a dx. (uh oh)

http://oig.hhs.gov/fraud/docs/alertsandbulletins/hospice2.pdf

Specifically, the Advisory Bulletin highlights several practices which indicate that some hospice providers may have inappropriately maximized their Medicare reimbursements at beneficiary expense. These practices include:

Making incorrect determinations of a person’s life expectancy for purposes of meeting hospice eligibility criteria;

Encouraging hospice beneficiaries to temporarily revoke their election of hospice during a period when costly services covered by a plan of care are needed in order for the hospice to avoid the obligation to pay for such services.

Once a Medicare beneficiary elects hospice care, the hospice is responsible for furnishing directly, or arranging for, all supplies and services that relate to the beneficiary’s terminal condition, except the services of an attending physician. Hospice beneficiaries have the right to receive covered medical, social and emotional support services from the hospice directly, or through arrangements made by the hospice, and should not be forced to seek or pay for such care from non-hospice providers.

The Office of Inspector General also has uncovered situations where duplicate claims were submitted by a hospice and other providers (such as

skilled nursing homes and hospitals) for services related to the beneficiary’s terminal illness. In a nationwide audit of services provided to Medicare beneficiaries enrolled in hospice programs, approximately $21.6 million

was improperly paid to hospitals and nursing homes for the treatment of hospice beneficiaries. Hospices are required to make financial arrangements for hospitalization, nursing services and all other health care needs related to the beneficiary’s terminal illness and included in the hospice plan of care. The cost of these services should be paid by the hospices.

•

A beneficiary has a right to expect a hospice to provide complete and accurate information about the consequences of hospice election and revocation.

A hospice is obligated to inform beneficiaries or their representatives that by electing the hospice benefit, they waive all rights to curative treatment or other standard Medicare benefits related to the terminal illness, except for the services of an attending physician. Some hospices inappropriately induce beneficiaries or their representatives to enroll in the hospice program without explaining that hospice election results in forfeiture of curative treatment benefits under Medicare.

The Office of Inspector General also has learned of hospices which induce beneficiaries to revoke the hospice election if expensive palliative treatment, even for a temporary period, becomes necessary. As a consequence, beneficiaries may then be burdened with substantial co-payments that would not be charged under hospice.

rnboysmom · Mar 28, 2009

Google the terms "southerncare" and "24.7 million" and "whistleblower" as mentioned in another post on another topic. Is this the company you work for? If not, the reading is interesting and if you really believe the company you work for is committing fraud--report them (only be sure to report them to the government--not their corporate company). You might make enough under the "whistle blower" law to retire!!