Hospices Can Manage Part D Audit Risks

Hospice is a Medicare Part A benefit, making hospice providers wholly responsible for providing all care related to a terminal diagnosis and comorbidities at no cost to the patient. This includes medications. While Part D plans may cover medications determined to be unrelated to the patient’s hospice enrollment, current regulatory guidance from the Centers for Medicare and Medicaid Services (CMS) states that billing for unrelated services during hospice enrollment should be “exceptional, unusual and rare.” If the patient or caregiver disagrees with the hospice plan of care and refuses to accept medications prescribed to meet the assessed needs, then the hospice is required to document this in the clinical record.

Part D audits can be costly for hospices, as plan sponsors can recover claims going back several years. Hospices can manage compliance risk by carefully reviewing their pharmacy utilization. Enclara Pharmacia provides several reports in our Enclarity™ business intelligence dashboards to help hospices identify patients whose medication claims may be misdirected to alternate payers.

The following are examples of Enclarity reports designed to help improve care and compliance while lowering costs across hospice organizations.

Patients With No Rx

If an active patient has no prescription claims, this could indicate that local pharmacy claims are still being billed to a Part D plan rather than through the Enclara PBM card. This is a common issue in skilled nursing facilities and when hospices utilize retail pharmacies, which already have a patient’s insurance information on file. It usually occurs early in hospice enrollment before the Part D plan has processed the patient’s hospice election notification.

Profiled and Covered Medications Not Dispensed

In some cases, medications are included in the patient’s medication profile and listed as covered but have not been dispensed through Enclara within the time frame selected. This is often an issue when the hospice routes prescriptions for emergent symptoms to a local pharmacy for caregiver pickup. The pharmacy may have the patient’s Part D plan on file and if the claim goes through, they will not contact the hospice prescriber.

Covered/Not Covered

The Covered/Not-Covered report displays all medications profiled for a patient and the coverage determinations as reported by the hospice. This provides an opportunity to review whether the medication coverage status was entered correctly. In some cases, medications are improperly marked as not covered when they are not on the hospice formulary. Hospices are responsible for covering non-formulary medications if their formulary lacks an appropriate alternative for a medication related to the patient’s terminal diagnosis.

Related Not Covered

CMS devotes extra attention to four medication classes (analgesics, anti-emetics, laxatives, and anti-anxiety medications), which are considered integral to hospice care. The Related Not Covered report identifies any patient on one of these classes for whom the medication is marked as not covered. It is important to note that these drug classes are not the only ones that hospices are required to provide. Rather, they are classes which are most likely to be appropriate for all patients regardless of terminal diagnosis and comorbidities.

The Enclara Difference

The reports described here are standard offerings in the hospice pharmacy industry, but Enclara takes business intelligence to a whole other level. As the nation’s leading hospice PBM, we are able to provide exclusive benchmarking to provide additional context and deeper insights. Our account and clinical management teams work with hospice leadership to identify opportunities for improvement and educate interdisciplinary teams to optimize prescribing practices. We understand that utilization is more than just a cost center. It’s a window to the patient experience. Through a technology-driven, consultative approach to business intelligence, Enclara helps hospices deliver care in alignment with their values and financial goals. It’s yet another way we deliver on our promise: You deliver the care; we make it easier.

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