The Call You Make at Admission Comes Back Four Times

Every hospice admission produces a determination about each medication the patient arrives with, and whether hospice is responsible for paying for it. The work is clinical from beginning to end, running from a nurse's first pass at the medication list, through the interdisciplinary group's review, to the physician who carries the final call.

That determination is also an answer four separate organizations will come looking for, each on its own schedule. A pharmacy needs it when it processes the medications. A family needs it in writing within five days. A Part D plan may come asking two years after the fact. CMS and its contractors can request it outright, and they also watch what follows from it in the claims data. None of those four is new. What changes on October 1st is that the family no longer has to ask.

Why those particular drugs stop at the counter

The pharmacy has been asking this question the longest, and it is worth knowing why.

Roughly a decade ago the Office of Inspector General looked at what Medicare was paying for hospice patients' prescriptions and made a plain observation: people tend to need the same few things at the end of life regardless of diagnosis, and those things are pain relief, something for nausea, something for constipation, and something for anxiety. CMS built its response directly on that, asking Part D plans to hold four categories of drugs for any enrollee known to have elected hospice: analgesics, antinauseants, laxatives, and antianxiety drugs.

The hold attaches to the patient rather than to any particular prescription. Medications outside those four categories process normally, so a hospice patient's blood pressure medication moves through Part D without issue. Inside the four, the presumption runs the other way. Those drugs are assumed to be the hospice's responsibility until the hospice says otherwise, and what says otherwise is the relatedness determination.

That notification is optional, so a hospice can be unaware that a patient stood at a counter and left without their medication.

The other three come looking on their own schedules

The one drawing attention right now is the family. For elections beginning October 1st, the hospice non-covered items addendum stops being something a family has to request and becomes something every family receives, in writing, within five days of the election effective date. We wrote last week about what that changes. The determination now goes to the family in writing, in language they can follow.

A Part D plan comes looking long after anyone is thinking about that admission. It reviews claims it paid during a hospice election period, concludes some of them were the hospice's responsibility, and sends a letter. That letter typically covers a year's worth of claims for hospice patients and can run up to several years behind. A hospice reading one this fall could be answering for medications dispensed in 2023 or 2024. Every plan formats it differently, sets its own timeline, and follows its own process, which leaves the hospice managing each plan's version of the same conversation.

CMS doesn't send anything at all. Three of the target areas in a hospice's PEPPER report count Part D claims per episode, broken out by whether the patient was at home, in an assisted living facility, or in a nursing facility. The service and spending variation index published with this year's final rule scores non-hospice spending as half of its sixteen points. Neither one is an audit and neither triggers one, though both are read by people who make decisions about a hospice. Surprise costs years after a patient is off service can add complexity to an already strict budget in a capitated payment environment.

Why answering is harder than deciding

A letter from a Part D plan listing two-year-old claims they say should have been covered by hospice can lead to two difficult situations.

In the first, a determination was made and the reasoning is difficult to recover. It happened in a conversation, it was clinical and usually sound, but it was never written anywhere a stranger could follow. The person opening the letter in operations was not at that meeting, and the nurse who did the initial review may not work there anymore, so the reasoning has to be rebuilt rather than retrieved.

The second is different in kind. A patient can be receiving an automatic mail-order refill from a pharmacy nobody at the hospice has spoken to, and a drug the hospice never knew about is a drug nobody assessed. There is no determination to recover and better documentation would not have produced one.

Both arrive in the same envelope and the ways out are narrower than they look. Reversing and reprocessing the claim is theoretically possible, though few pharmacies will touch one older than about three months and audit claims are routinely years old. What remains is defending the determination in writing or paying the plan.

Where the reasoning was captured at the moment it was made, answering is a retrieval rather than an investigation, and those claims tend not to be the ones that surface on an audit list to begin with. The work that makes the letter easy to answer is the same work that makes the letter less likely to arrive.

The two documents ask the same question

CMS publishes a standard form for the Part D side of this, called Hospice Information for Medicare Part D Plans. Its stated purpose is to document that a drug is unrelated to the terminal prognosis, and its instructions are explicit that it is meant to be used before a claim is submitted rather than after one rejects.

Set that form next to the addendum and the overlap is hard to miss. The addendum lists the drugs the hospice will not cover and explains why, in language the family can follow. The Part D form identifies drugs the hospice will not cover that fall inside the four held categories, so the plan knows it can pay them. One goes to the family and the other goes to the plan, and both are built from a determination the interdisciplinary group has already made.

From October 1st that determination gets written down at every admission whether anyone requests it or not. A hospice that treats the finished addendum as the trigger, and sends the Part D form for anything on it that falls inside the four categories, gets a second return on work it now has to do anyway. The plan learns the hospice's reasoning while the patient is still on service rather than in a letter two years later, and the drugs the family was told are not covered are the same drugs the plan has been told it can pay.

Nothing on that list is a compliance exercise. Every item is something a hospice would want to know anyway in order to take good care of the patient. The compliance value is a byproduct.

Run together, the two documents add no step to the admission. They move an existing one earlier, to the point where it prevents a rejection at the counter, keeps a plan from writing a letter, and leaves the reasoning on file with the one organization most likely to ask for it later. The new requirement is the occasion for that, not the cost of it.

What this looks like with MerlinRx

MerlinRx is built so the answers to those questions exist at the moment the determination is made rather than being assembled after somebody asks.

The medication picture comes together before admission, including the parts of it a hospice would otherwise learn about from a rejection. When the team decides a drug is unrelated, the reasoning stays attached to the decision, so retrieving it two years later is a matter of looking rather than remembering.

The effect shows up furthest from the office. The claim processes at the counter, so the family is not standing at a pharmacy hearing that something has been declined. The determination the family reads is the one that holds, and revising it remains available under the rule without becoming the routine. The letter that arrives two years from now takes an afternoon instead of a month.

The determination is one decision

None of the four organizations reading it will ever see each other's version. The pharmacy sees a reject code, the family sees a document, the plan sees a claim, and CMS sees a rate. Behind all four is a single judgment, made early and in one place, and none of the four will ever see it in the form it was made.

Getting it right the first time is not about permanence, as the rule allows the addendum to be updated within three days when the plan of care changes. It is that a determination made carefully and written down clearly is the one that holds up at every point it gets read, and the one nobody has to explain twice.