Geriatric Nursing 35 (2014) 464e465
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Legal Column
Howard L. Sollins
Donna J. Senft
Susan A. Turner
Changes to hospice attending physician rules Donna J. Senft, PT, JD * Principal, Ober, Kaler, Grimes and Shriver, 100 Light Street, Baltimore, MD 21202, USA
Medicare’s 2015 payment policy changesa usher in new requirements for nurse practitioner services provided to hospice patients. New Medicare regulations require hospices to follow specific procedures to designate and change a hospice patient’s attending physician.b The policy change was prompted by CMS0 concern that attending physician changes were being made without the hospice patient’s consent. The Medicare statute defines an “attending physician” for a hospice patient to be the physician or nurse practitioner who the patient “identifies as having the most significant role in the determination and delivery of medical care. at the time the individual makes an election to receive hospice care.”c Since the Medicare statute was written to promote choice, by requiring the patient to identify his or her attending physician when electing to receive hospice care, CMS was concerned that subsequent attending physician changes were occurring absent a patient’s decision to do so. CMS was prompted to take action based on recent anecdotal reports that hospice patients’ attending physicians were routinely being changed when the patients transitioned to receive care in an inpatient setting. CMS also noted that past reports indicated attending physicians were selected, at times, based on who was available to provide care. Furthermore, CMS cited to 2010 and 2011
* Corresponding author. Tel.: þ1 410 347 7336, þ1 410 258 5080 (mobile); fax: þ1 443 263 7536. E-mail address: [email protected]. a The 2015 payment policy changes are effective October 1, 2014, which is the start of the new federal fiscal year. b See Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update, 79 Fed. Reg. 163, pp. 28e32 (Aug. 22, 2014). Available on the Internet at: http:// www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18506.pdf. c 42 U.S.C. x 1395(x)(dd)(3)(B). Since “attending physician” is a defined term under Medicare law, this article will continue to reference attending physician, which by definition includes nurse practitioners. 0197-4572/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.10.003
data which revealed that Part B payments were made to more than one physician claiming to be the hospice patient’s attending physician in 35 percent of the cases reviewed. The Medicare “Election of Hospice Care” regulations were amended to require the hospice election statement to note the patient’s attending physician choice. This requirement was finalized as proposed despite concerns that having to designate the attending physician when the election statement is signed might result in delays in initiating hospice care. In response to this concern, CMS noted that it has been a requirement for over 30 years to identify the attending physician when hospice care is elected. CMS did not, therefore, understand how requiring the information to be noted on the election statement would delay care. In addition to identifying “the attending physician that will provide care” to the hospice patient, the election statement must include an acknowledgment “that the identified attending physician was his or her choice.”d Furthermore, if the hospice patient chooses to make an attending physician change, the hospice will be required to follow procedures similar to those currently in place for a patient to designate a new hospice provider. The Medicare regulations were amended to require a statement signed by the patient noting the attending physician change. More specifically, the statement must identify the new attending physician, the effective date for the change, and an acknowledgment that it is the patient’s choice to do so.e The new regulations prohibit the use of a retroactive effective date. The earliest that the change may be effective is the date the statement is signed, even if a hospice patient verbally expressed a desired to make the change prior to signing the statement.
d e
42 C.F.R. x 418.24(b)(1). 42 C.F.R. x 418.24(f).
D.J. Senft / Geriatric Nursing 35 (2014) 464e465
And, CMS cautioned hospices to ensure that the attending physician is noted on the election statement or change form with enough particularity to clearly identify the physician or nurse practitioner who the patient is choosing. The location of the attending physician’s practice may need to be included if the individual has a common name and it would not be apparent which provider is being chosen. Hospices should act promptly to modify its election statement or change form to include these new requirements. CMS noted that among the many legitimate reasons a hospice patient may choose to change an attending physician, having to choose a new attending physician upon admission to an inpatient hospice setting is not one. CMS emphasized that a hospice patient may not be required to make an attending physician change upon admission to an inpatient setting, irrespective of the setting. The hospice Conditions of Participation (CoPs) provide for handling a situation in which the attending physician does not have privileges or does not wish to provide care at the hospital or nursing facility where the hospice patient is located. Under the CoPs, a hospice physician or nurse practitioner is required to provide any needed medical services that the hospice patient’s attending physician does not provide.f Should a hospice physician or nurse practitioner need to render medical care to a hospice patient in an inpatient stay, the patient does not need to sign any statement designating this appointment. The hospice would not, however, be able to capture any charges for services provided by a hospice nurse practitioner in these
f g h
42 C.F.R. x 418.64(a)(3). 42 C.F.R. x 418.56. 42 C.F.R. x 418.112.
465
situations. Although the Medicare regulations allow a hospice to bill for certain medically necessary service provided by a hospice physician, payment may only be made for services provided by a nurse practitioner when the nurse practitioner is the hospice patient’s designated attending physician. When discussing inpatient care needs, CMS highlighted the responsibility of the hospice to coordinate patient care during the inpatient stay. CMS noted the importance of ensuring the hospice physician or nurse practitioner is in communication with hospitalists (in the hospital setting) and medical directors (in the nursing facility setting). In response to comments that a nursing facility’s attending physicians or medical director should be primarily responsible for addressing medical needs during an inpatient hospice stay in a nursing facility unit, CMS responded that the hospice CoPs require the hospice to be responsible for care coordination in all settings.g CMS further cited to the hospice CoPs addressing situations in which a hospice patient resides in a nursing facility and requiring the hospice to assume responsibility for the professional management of the resident’s hospice care as provided for in the hospice care plan.h These CoPs further require a written agreement between the hospice and nursing facility which includes provisions addressing care coordination and requires the hospice to assume responsibility for determining the appropriate course of hospice care, including determinations to change the level of services. Hospices should review written agreements with inpatient settings to be sure that the agreements comply with the CoPs.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Legal Column
Howard L. Sollins
Donna J. Senft
Susan A. Turner
Changes to hospice attending physician rules Donna J. Senft, PT, JD * Principal, Ober, Kaler, Grimes and Shriver, 100 Light Street, Baltimore, MD 21202, USA
Medicare’s 2015 payment policy changesa usher in new requirements for nurse practitioner services provided to hospice patients. New Medicare regulations require hospices to follow specific procedures to designate and change a hospice patient’s attending physician.b The policy change was prompted by CMS0 concern that attending physician changes were being made without the hospice patient’s consent. The Medicare statute defines an “attending physician” for a hospice patient to be the physician or nurse practitioner who the patient “identifies as having the most significant role in the determination and delivery of medical care. at the time the individual makes an election to receive hospice care.”c Since the Medicare statute was written to promote choice, by requiring the patient to identify his or her attending physician when electing to receive hospice care, CMS was concerned that subsequent attending physician changes were occurring absent a patient’s decision to do so. CMS was prompted to take action based on recent anecdotal reports that hospice patients’ attending physicians were routinely being changed when the patients transitioned to receive care in an inpatient setting. CMS also noted that past reports indicated attending physicians were selected, at times, based on who was available to provide care. Furthermore, CMS cited to 2010 and 2011
* Corresponding author. Tel.: þ1 410 347 7336, þ1 410 258 5080 (mobile); fax: þ1 443 263 7536. E-mail address: [email protected]. a The 2015 payment policy changes are effective October 1, 2014, which is the start of the new federal fiscal year. b See Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update, 79 Fed. Reg. 163, pp. 28e32 (Aug. 22, 2014). Available on the Internet at: http:// www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18506.pdf. c 42 U.S.C. x 1395(x)(dd)(3)(B). Since “attending physician” is a defined term under Medicare law, this article will continue to reference attending physician, which by definition includes nurse practitioners. 0197-4572/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.10.003
data which revealed that Part B payments were made to more than one physician claiming to be the hospice patient’s attending physician in 35 percent of the cases reviewed. The Medicare “Election of Hospice Care” regulations were amended to require the hospice election statement to note the patient’s attending physician choice. This requirement was finalized as proposed despite concerns that having to designate the attending physician when the election statement is signed might result in delays in initiating hospice care. In response to this concern, CMS noted that it has been a requirement for over 30 years to identify the attending physician when hospice care is elected. CMS did not, therefore, understand how requiring the information to be noted on the election statement would delay care. In addition to identifying “the attending physician that will provide care” to the hospice patient, the election statement must include an acknowledgment “that the identified attending physician was his or her choice.”d Furthermore, if the hospice patient chooses to make an attending physician change, the hospice will be required to follow procedures similar to those currently in place for a patient to designate a new hospice provider. The Medicare regulations were amended to require a statement signed by the patient noting the attending physician change. More specifically, the statement must identify the new attending physician, the effective date for the change, and an acknowledgment that it is the patient’s choice to do so.e The new regulations prohibit the use of a retroactive effective date. The earliest that the change may be effective is the date the statement is signed, even if a hospice patient verbally expressed a desired to make the change prior to signing the statement.
d e
42 C.F.R. x 418.24(b)(1). 42 C.F.R. x 418.24(f).
D.J. Senft / Geriatric Nursing 35 (2014) 464e465
And, CMS cautioned hospices to ensure that the attending physician is noted on the election statement or change form with enough particularity to clearly identify the physician or nurse practitioner who the patient is choosing. The location of the attending physician’s practice may need to be included if the individual has a common name and it would not be apparent which provider is being chosen. Hospices should act promptly to modify its election statement or change form to include these new requirements. CMS noted that among the many legitimate reasons a hospice patient may choose to change an attending physician, having to choose a new attending physician upon admission to an inpatient hospice setting is not one. CMS emphasized that a hospice patient may not be required to make an attending physician change upon admission to an inpatient setting, irrespective of the setting. The hospice Conditions of Participation (CoPs) provide for handling a situation in which the attending physician does not have privileges or does not wish to provide care at the hospital or nursing facility where the hospice patient is located. Under the CoPs, a hospice physician or nurse practitioner is required to provide any needed medical services that the hospice patient’s attending physician does not provide.f Should a hospice physician or nurse practitioner need to render medical care to a hospice patient in an inpatient stay, the patient does not need to sign any statement designating this appointment. The hospice would not, however, be able to capture any charges for services provided by a hospice nurse practitioner in these
f g h
42 C.F.R. x 418.64(a)(3). 42 C.F.R. x 418.56. 42 C.F.R. x 418.112.
465
situations. Although the Medicare regulations allow a hospice to bill for certain medically necessary service provided by a hospice physician, payment may only be made for services provided by a nurse practitioner when the nurse practitioner is the hospice patient’s designated attending physician. When discussing inpatient care needs, CMS highlighted the responsibility of the hospice to coordinate patient care during the inpatient stay. CMS noted the importance of ensuring the hospice physician or nurse practitioner is in communication with hospitalists (in the hospital setting) and medical directors (in the nursing facility setting). In response to comments that a nursing facility’s attending physicians or medical director should be primarily responsible for addressing medical needs during an inpatient hospice stay in a nursing facility unit, CMS responded that the hospice CoPs require the hospice to be responsible for care coordination in all settings.g CMS further cited to the hospice CoPs addressing situations in which a hospice patient resides in a nursing facility and requiring the hospice to assume responsibility for the professional management of the resident’s hospice care as provided for in the hospice care plan.h These CoPs further require a written agreement between the hospice and nursing facility which includes provisions addressing care coordination and requires the hospice to assume responsibility for determining the appropriate course of hospice care, including determinations to change the level of services. Hospices should review written agreements with inpatient settings to be sure that the agreements comply with the CoPs.
