Hospice is a treatment philosophy that focuses on comfort and quality of life. People are often surprised to learn that it is also a special benefit under Medicare that pays for a great deal more supplies, medications and services than other insurance benefits. Qualifying for hospice care is relatively straightforward. The patient must have Medicare Part A and their physician must certify that they are likely to die hospice care provider within six months if their life-limiting condition runs its expected course. Prognosticating on dying patients, on the other hand, can sometimes be difficult. Research has shown that some patients actually improve with the addition of hospice services and other patients’ rate of decline may be slower than expected. This problem of prognostication is causing hospices to experience increased government scrutiny. At the core of this scrutiny is concern that patients who are receiving hospice care may be chronically ill rather than terminally ill and therefore, ineligible for hospice care. The fact is that hospice serves only about 39% of all dying patients and 50% of those dying patients received care for only three weeks rather than 6 months.

This article deals with the most basic level of hospice scrutiny, Additional Development Requests or ADR’s. ADRs are when the Medicare Fiscal Intermediary or Medicare Administrative Contractor decides to withhold payment on a group of patients until the hospice sends documentation that confirms that the patient met both technical and medical eligibility criteria. If multiple claims are denied, the hospice will experience delays in payment and eventual financial hardship. The end result may be that fewer patients receive hospice care because the hospice becomes fearful that accepting patients early could result in ADRs or audits and subsequent financial hardship.

There are some simple changes in documentation that the hospice clinical staff can make to ensure medical eligibility is well documented and Medicare denials avoided.

First, document at least monthly all significant changes in the patient’s condition that indicate decline especially those outlined by the Local Coverage Determination (“LCDs”) established by Medicare. Play close attention to weight loss or changes in mid-arm circumference measurements. Consider that dysphagia is not just coughing after swallowing but is a constellation of symptoms including: drooling, refusal to eat certain foods, a hoarse voice or gurgling sounds after eating.