Reimbursement challenges for advanced care planning and end-of-life care

March 26, 2019
Medicare Web

Countless ethical challenges are on the end-of-life care platter for case managers:

  • Managing compassionate weans
  • Clients transferred inappropriately; dying as they are being transferred or immediately after
  • Not knowing what extent of treatment a client wants
  • Client and family disagreement about advance directives
  • Treatment team and client disagreement
  • Two extremes: Either everybody involved or nobody
  • Cultural issues

Even when individuals and families are aligned, other issues may not be in sync, like societal norms, personal and professional values, and payer requirements.

With less than 50% of Medicare beneficiaries utilizing hospice programming, CMS and the industry saw that changes needed to occur. As a result, a new age of hospice reimbursement appeared in 2016. Updated Medicare payment codes appeared in the Medicare Physician Fee Schedule for practitioners to consult with clients on how they would like to be cared for as they are dying:

  • An initial code for 30 minutes of discussion on advance care planning
  • An add-on code for each additional 30 minutes

Hospice payments have risen in tandem with expenditures. Hospice encompasses the cost of visits, as well as other costs a hospice incurs for palliative care and management of the terminal condition and related conditions (e.g., on-call services, care planning, drugs, medical equipment, supplies, patient transportation between sites of care specified in the plan of care, short-term hospice inpatient care). Services by volunteers and ongoing bereavement support for family members and support systems are also covered by the benefit. A number of payers, including Humana and BlueCross, have acquired hospice programs or expanded their hospice benefits and offerings.

The Medicare Care Choices Model (MCCM) was put into place through the Innovation Center. Under the Affordable Care Act (ACA), children enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) are eligible to receive curative treatment and hospice care simultaneously. Curative treatment refers to healthcare practices used to treat clients with the intent of curing them and not simply to reduce their pain or stress (e.g., chemotherapy).

The Centers for Medicare & Medicaid Services (CMS) is amid a five-year, 40-state test program to determine a better way to help adult beneficiaries deal with end of life. Hospices participating in the model were randomly assigned to phase 1 or phase 2, with 141 hospices initially chosen to participate. The demonstration project provides end-of-life care and counseling to dying Medicare beneficiaries at the same time those persons receive treatment to extend their lives. Delivery of services under the model is phased in over two years. As of January 2018, 97 hospices were involved, with the model to end on December 31, 2020. Further information about the MCCM can be found here.


Editor's note: For more information see The Essential Guide to Interprofessional Ethics in Healthcare Case Management.

Related Topics: 
Case Management