What is and isn't allowed on Hospice?

tewdles, RN · Sep 4, 2012

The contracted hospice must pay for care related to the terminal diagnosis as outlined within the hospice plan of care (POC). Because hospice is paid on a "per diem" basis rather than a fee for service basis, all care is paid for out of the daily reimbursement provided by the insurer.

Most hospice agencies try to minimize their expenses by denying inclusion of expensive tests and procedures in the POC. I, for example, have never worked for a hospice agency that PLANS to pay for CT scans, x-rays, etc, that would be considered expensive and diagnostic. (note that I have worked for 5 agencies in 3 states)

Some hospice agencies have included language in the election of benefit which indicates that the family understands that if they seek urgent, acute, or other medical care or services without collaboration with the IDT and consent of the IDT that their election will be considered revoked. In the scenario that you mentioned the family would be expected to revoke the hospice benefit when they opt to visit the ED rather than follow the hospice POC. The revocation is immediate and the insurer can be billed for the ED visit and subsequent tests and care will be covered under the original insurance plan.

Does this help?

RachelRN25 · Sep 5, 2012

Thanks!! Yes, that does help! It sounds like it varies quite a bit from agency to agency. I always thought Medicare rules were pretty black and white when it came down to what was covered. I guess I'll just have to ask my company that I work for what they do. Thanks again! :)

westieluv · Sep 5, 2012

It can be confusing because, like Tewdles said, if a patient or their family make the decision to take the patient to the hospital for curative treatment and without contacting the hospice team to discuss options with them first, in most cases this leads to revocation of hospice service. However, if the patient is experiencing an uncontrolled symptom related to their hospice diagnosis, such as severe pain or vomiting that is not being managed by their home hospice meds and they call the hospice staff to report it, often times the patient will be admitted to the hospital as a GIP (general inpatient) for symptom control and then the hospice will pick up the tab since the hospitalization is not considered curative treatment but symptom management related to the patient's hospice diagnosis. The hospice I worked for most recently also paid if a patient was required to have a chest X-ray before being transferred from home to a LTC facility if the family could no longer meet their needs at home. We also had a patient who had end stage ALS and was on Coumadin secondary to the disease process and our hospice paid for his PT/INR lab draws every 2-4 weeks.

It's all about whether or not it is related to their Medicare appropriate hospice diagnosis and if it's considered curative or not. If someone with stage IV lung cancer with brain mets suddenly decides to go to the hospital and request additional chemo, even though chemo didn't help them before and their doctor feels that there is no chance for a cure, then they are no longer a hospice patient because they are seeking curative treatment.

This is how I understand it to work, and I have worked for two, going on three, hospice companies in recent years.

RachelRN25 · Sep 5, 2012

Thanks Westieluv! Your comment was good and helped put some pieces of that puzzle together in figuring how the Medicare/Hospice system. Thanks! :)