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Minimizing Hospice Billing Concerns

By November 21, 2022December 1st, 2022CMS, November 2022, Part D

What is the Issue?1

In August 2019, the Department of Health and Human Services Office of Inspector General (OIG) released a report entitled, Medicare Part D is Still Paying Millions for Drugs Already Paid for Under the Part A Hospice Benefit, that identified $422.7 million in 2016 Part D total costs attributed to beneficiaries receiving hospice care at the time the drug was filled. This same report encouraged the Centers for Medicare & Medicaid Services (CMS) to identify and implement additional measures to avoid paying twice, under Part D and under the hospice benefit, for the same drugs. At the time, the OIG recommended the following solutions:

  • CMS should work directly with hospices to ensure that they are providing drugs covered under the hospice benefit
  • CMS should implement a process to ensure that Part D does not pay for drugs covered under the hospice benefit

Part D spending for beneficiaries receiving hospice care continued to grow and in 2022 CMS reported that 2019 Part D spending for these beneficiaries grew to almost $500 million. CMS attributed the continued growth in Part D spending for drugs covered under the hospice benefit to the delay in CMS’ notification to Part D sponsors that beneficiaries are receiving Medicare covered hospice care.

What Is CMS Doing?2,3

CMS has partnered with RelayHealth, the Medicare Part D Transaction Facilitator, to design a hospice election notification system to provide notice of a beneficiary’s hospice election to Medicare Part D sponsors in real time, allowing Medicare Part D sponsors to appropriately reject claims for drugs that may be related to the beneficiary’s hospice indication. To date, the hospice pilot has reduced the duration for notification of hospice election to Medicare Part D sponsors from 22 days to a maximum of 48 hours via a hospice Nx information transaction. CMS expects that once fully implemented hospice election information will be sent to Part D sponsors within 2 hours of CMS receiving the hospice information.

However, CMS continues to audit Part D plans and in July 2022 provided advanced notice of the Center for Program Integrity’s National, Self and Program Integrity audit schedule for calendar years 2022 and 2023. Specifically, CMS has indicated that drugs provided to enrollees who have elected hospice care will be targeted for the self-audits. These self-audits will determine whether PDE records were appropriately paid for under Part D or should have been paid for under the hospice benefit. These audits began in October 2022 and will continue throughout 2023.

What Can Plans Do?

Sponsors may be wondering what they can do to ensure that drugs for hospice beneficiaries are billed to the appropriate benefit. Sponsors can and should implement strategies to minimize inappropriate billing of hospice-related drugs to Part D include the following:

  • Ensure that a hospice payment recovery and PDE exclusion processes for claims identified as having paid inappropriately under the Part D benefit are in place and documented.
  • Ensure that there are processes and controls within the coverage determination and appeals areas to verify hospice determinations.
  • Ensure that hospice adjudication drug lists are accurate and maintained regularly.

Regardless of when CMS implements a final process to provide timely delivery of hospice election information, plans must remain diligent and ensure that their oversight and monitoring processes include the ability to review claims that paid under Part D for beneficiaries who have elected hospice.

  1. Department of Health and Human Services Office of Inspector General. Medicare Part D is Still Paying Millions for Drugs Already Paid for Under the Part A Hospice Benefit (A-06-17-08004). August 2019.
  2. National Council for Prescription Drug Programs. Presentation: Hospice Election Status NCPDP/CMS Pilot. June 29, 2022.
  3. Centers for Medicare & Medicaid Services Center for Program Integrity. Advance Notice of the Center for Program Integrity’s (CPI) National, Self, and Program Integrity Audit Schedule for Calendar Years (CY) 2022 and 2023. July 21,2022.