A good balancing act reduces risk

Avoid cap deficits by managing case-mix

Balancing your case-mix to avoid hospice cap deficits doesn't mean discharging patients or admitting patients who don't meet hospice criteria, warns Kyle Terry, MBA, consultant and principal at Hospice CAP Consultants in Owasso, OK. "Although a balance of short- and long-term patients is the best strategy to minimize your risk of receiving a repayment demand letter from CMS based upon the hospice cap, it is important to follow admission criteria guidelines issued by CMS," he says.

After you've evaluated your cap deficit risk, look at the types of patients you typically admit and at your referral sources, Terry suggests. "Then, look at where your marketers are going," he says. "Generally, oncologists will refer shorter term patients and family practitioners will refer longer term patients, many of whom may be in nursing homes," he explains. To ensure a balanced case-mix, make sure your marketers are visiting all types of referral sources, he adds.

Monitor your admissions on a monthly basis with a focus on how your patient mix affects your cap deficit or surplus, says Terry. "By watching on a monthly basis, you have an opportunity to make changes and redirect marketers in a timely manner," he says.

Tricks such as not filing a claim with CMS until after the start of a new fiscal year won't work, warns Terry. "The calculations are not based upon the date the claim is received, they are based upon the dates on which services were provided," he says.

Staff members, not just marketers, should be included in discussions about the need for a variety of patients, says Terry. "Staff members are sources of referrals also because their friends and families are likely to choose the hospice because they know someone who works there," he says. "I was always very open with my staff about the reality of the hospice cap and how we could work together to avoid repayment demands."