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How To Work With Hospice

    HOSPICE ADMISSION CRITERIA



    Medicare Amendments for Attending Physicians

    SUBJECT : Clarification of Physician Certification Requirements for Medicare Hospice

    Section 1814(a)(7) of the Social Security Act (the ACT) contains the requirement for Medicare hospice that a physician certify in writing at the beginning of a benefit period, that a beneficiary is terminally ill. Section I86I (dd)(3)(A) explains that an individual is considered to be "terminally ill" if the individual has a medical prognosis that the individual's life expectancy is 6 months or less. Federal Regulations at 42 CFR 418.3 further clarify' that an individual is considered co be terminally ill if they have a medical prognosis of a life expectancy of 6 months or less if the illness runs its normal course.

    Subtitle C, 322, of the Benefits Protection and Improvement Act (BIP A) of 2000 amends 1814(a)(7) of the Act by clarifying that the certification of terminal illness of an individual who elects hospice “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual's illness." This clarification is effective for certifications made on or after the date of BIP A enactment which was December 21,2000.

    The amendment to 1814(a)(7) of the Act clarifies current policy, that the certification is based on clinical judgment regarding the normal course of illness, and further emphasizes the understanding that making medical prognostication of life expectancy is not always exact.

    Intermediaries should inform hospice providers of this statutory clarification of current Medicare policy within 30 days of the implementation date.

    Carriers should publish this instruction in their next regularly scheduled bulletin following the implementation date.

    The effective date for this Program Memorandum (PM) is December 21, 2000.

    The implementation date for the PM is February 1, 2001.

    These instructions should be implemented within your current operating budget. This PM may be discarded after February1, 2002.

    If you have any questions contact Lynn Riley at (410) 786-1286.

    Due to short length stays of the hospice benefit, MEDICARE has implemented a change in physician certification and will monitor the results over the next two years. This rule now clarifies the 6 months or less rule which is the physician’s opinion of the patient’s life expectancy. The rule further clarifies for the physician that Medical Prognostication of Life Expectancy is not always exact. This clarifies the ongoing and common hesitation with physician liability regarding the exactness of prognostication of 6 months or less.

    In 1982, the MEDICARE hospice benefit was established to provide extra services for terminally ill patients and their families. The idea was correct; the outcome fell short due to the question of what is the appropriate criterion for a hospice referral. Hopefully the professional community will now have a better understanding of when it is appropriate to refer without fear of a liability for their prognostication. Again the hospice remains responsible for the ongoing certification of hospice appropriateness.

    This is a wonderful opportunity for all of us to feel comfortable in providing the much-needed and under-utilized hospice benefit within our community for terminally ill persons.