Best Practices

1
Best Practices

• Hospice Edit

2
Background

• Pharmacy Review suspected that a potential
  problem existed whereby pharmacies could be
  billing the Outpatient Pharmacy Program for
  medications that should have been paid by hospice
• Working in collaboration with Clinical Policy ,
  it was determined that a large number of claims
  were being billed that should be covered by the
  hospice benefit for recipients who elected
  hospice

3
Medicaid Hospice Benefit

• Coordinated program of services that provides
  medical, supportive and palliative care to
  terminally ill recipients and their
  families/caregivers
• Coverage complies with North Carolina
  Administrative Code 10A NCAC 13K, North Carolina
  Rules Governing the Licensure of Hospice, N.C.
  General Statute G.S. 131 E-201, and or Federal
  Code of Regulations 42 CFR 418
• Services are provided according to a care plan
  established by an interdisciplinary team of
  medical, professional and social support staff
  employed by or under contract with the hospice
  agency as allowed by CMS

4
Medicaid Hospice Benefit

• Services are provided in a variety of settings
  when there is a contractual arrangement between
  the hospice and the facility
• The hospice benefit covers all care pertaining to
  the terminal illness
• Specifically, 42 CFR 418.202 (f) states the
  following
• drugs which are primarily used for the relief of
  pain and symptom control related to the
  individuals terminal illness are covered

5
Solution

• Clinical Policy and the Fiscal Agent implemented
  an edit in the POS system
• If the patient is enrolled in hospice, all drug
  claims deny with the message recipient claim
  covered by hospice
• If the drug is used for an indication not
  directly related to the recipients terminal
  illness, then an override is available

6
Solution

• Placing a 1 in the PA field and the ICD 9 code
  in the diagnosis field for the patients terminal
  illness overrides the hospice edit
• Drug classes not allowed for overrides are the
  narcotic analgesics, hematinics, antiemetics and
  most chemotherapeutics
• A Pharmacy Review pharmacist monitors the hospice
  override report and recoups on the misbillings

7
Cost AvoidanceOver 900,000 saved in just 6
months

• Hospice Edit implemented February 2005
• Compare payment of drug claims for hospice
  clients Sep 2004 through Feb 2005 and after the
  edit March 2005 through Aug 2005.

8
Problems

• Over four years later, we still get the
  occasional protest call from the hospice provider
  or pharmacy provider
• Most often its because the pharmacy believes
  that because a drug is not on the hospice
  formulary, then Medicaid should pay
• Once everyone realizes the hospice is paid a per
  diem to cover all related services, the process
  becomes easier

9
Results

• We recoup money from the pharmacy and they in
  turn get their money back from the hospice
• We see very few overbillings in this area today
  since the pharmacists and hospices have been
  educated and pharmacies have learned by us
  recouping from them