Medicare Service Intensity Add-On Underused by Hospices

Hospice providers are not taking advantage of the Medicare Service Intensity Add-On (SIA) program, despite the program’s potential to drive quality improvement and increase revenues.

The U.S. Centers for Medicare & Medicaid Services (CMS) introduced SIA in 2016 to allow hospices to bill an additional payment on an hourly basis for registered nurse and social worker visits during the last seven days of a patient’s life in addition to their standard per diem reimbursement.

The number of registered nurse and social worker visits during a patient’s final week is one of the seven quality measures that CMS uses to evaluate providers for its Hospice Compare website, which allows consumers, payors, and referring organizations to benchmark performance of individual providers against one another. SIA providers a financial incentive for hospices to improve performance on the measure.


“Generally, providers know and understand that basics of SIA, but there is a lack of awareness about the operational impact that it has and how it can be optimized,” said Catherine Dehlin, director of hospice services for Northhampton, Mass.-based consulting firm Fazzi & Associates. “[Hospice] providers are aware of SIA, but they are not really taking advantage of it.”

Medicare hospice claims data for 2016 and 2017 show that increased payments have not led to significant improvement, with total skilled hours during the patient’s last week rising only 2.2% between 2016 and 2017.

CMS requires hospice providers to submit data for two measures pertaining to the number of visits a patient receives when death is imminent:

  1. The three-day measure assesses the percentage of patients receiving at least one visit from a registered nurse, physician, nurse practitioner, or physician assistant in the last three days of life.
  2. The seven-day measure assesses the percentage of patients receiving at least two visits from a social worker, chaplain or spiritual counselor, licensed practical nurse, or hospice aide in the last seven days of life.

“Visits in the last week of life are critical for patients and their families, and the hospice team can provide care and comfort from many different disciplines during that time,” Judi Lund Person, vice president, Regulatory and Compliance, National Hospice and Palliative Care Organization.

A number of factors contribute to low SIA utilization, ranging from logistics and staff shortages to providers’ anxieties about potential payor scrutiny and the inherent difficulty of predicting when a patient will expire.

“When SIA started in 2016 it was a payment change, so providers were concerned that changing the utilization of those visits at that point would be seen as a change in practice and would be scrutinized,” Dehlin said. “There was a myth that they shouldn’t change their practice, that they should continue with the status quo. As a result we have seen no change in visit utilization since 2016 in social work or nursing visits. In fact, 86% of patients don’t get a social work visit at all during the last seven days of life.”

While an organization’s leadership may understand how the program works, often managers and front-line staff do not including schedulers and the clinicians themselves. These often contribute to a less than optimal response when visits should be increased. Geography can also play a role; in a rural area a nurse may be travelling an hour or more between patients’ homes, complicating attempts at increased visits.

Staff education is key, according to Dehlin, particularly for new hospice clinicians. Clinicians need to be able to recognize the pre-active and active stages of dying and how the dying process typically progresses by disease process. Educate families about what they can expect can also help identify patients who are in the last week of life, and engaging families in the process tends to increase patient and family satisfaction.

“There are many different factors within the structure of the organization’s processes,” Dehlin told Hospice News. “Ensuring that processes for escalating services during the patient’s final week and ensuring timely communication among caregivers, allowing visits to be delegated to other clinicians when necessary so that visits at the end of life are not subject to one clinician’s schedule or location can all make a significant difference.”

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