Non-cancer admission policies revised

Controversy continues to simmer over access

Continuing controversy from providers surrounding the transformation of the Arlington, VA-based National Hospice Organization (NHO) Medical Guidelines for Defining Prognosis in Selected Non-Cancer Diseases into local medical review policies for fiscal intermediaries (see Hospice Management Advisor, November 1997, pp. 130-131), has persuaded intermediary medical directors to modify them yet again before implementing them. The changes mainly involve loosening some criteria and restoring certain language from NHO’s original voluntary guidelines, based on input from providers, including a session at the recent NHO annual meeting in Atlanta. NHO has also requested foundation funding to do research on the guidelines.

"I would argue that a lot fewer patients would be admitted," if the policies remained as the fiscal intermediaries (FIs) had first proposed, says Anne Thal, LCSW, DCSW, president and CEO of Hospice of Hillsborough in Tampa, FL. "My staff audited 145 non-cancer patient charts, all of whom died in six months or less, and 61% in 30 days or less. Of these charts, 64% would not have been admitted under the proposed criteria. To me that says they are too restrictive."

"We’ve made some changes in the language of the criteria, says Richard Baer, MD, associate medical director for Medicare Health Care Service Corporation in Chicago, the regional home health/hospice intermediary for Illinois, Ohio, and Indiana. Since intermediaries’ local review policies have not yet been published in final form, "we are able to make these changes across the board" nationwide, Baer adds. "One of the things that is still a problem — with providers fearing that they will be used to deny claims rather than to pay claims — is the absolute language, must instead of should. That’s a difficult nut for us. We need absolute language and hard-and-fast standards for medical reviewers to make a first-pass review."

The policies also allow hospices to request coverage for patients who don’t fit the published criteria, on an individual basis, so long as they provide evidence documenting why the patient is terminal, Baer says. "As these things move forward, people will have experience with the criteria used to approve claims." The criteria can also be adjusted based on new evidence and actual experience. Final policies were expected in Baer’s region by the end of the year, with other FIs following suit.

Even with the changes, however, the policies could create "very difficult times for providers with denials and for intermediaries" who must respond to providers’ appeals of denials based on the policies, says J.R. Williams, MD, chief patient care officer for Vitas Healthcare Corp. in Miami. "Some hospices will tighten up their admission practices in response, and the net effect will be to further decrease length of stay."

Brad Stuart, MD, hospice medical director for VNA and Hospice of Northern California in Emeryville, and co-author of the original NHO guidelines explains further. "I think the best thing to say is that most of the specific objections hospice medical directors had about the content have been agreed to as changes that need to be made at HCFA’s end."