Careful Billing, Expense Management Critical to Palliative Providers During Pandemic

While the coronavirus pandemic has brought to light the growing critical need for expanded palliative care programming, its economic ramifications have many providers navigating uncharted financial waters. Strategizing through the public health crisis will involve minimizing operational expenses while branching out to non-traditional revenue sources.

More than half of community-based palliative care providers in the United States are hospices, according to the Center to Advance Palliative Care (CAPC).

“Palliative care team leadership is challenged in the COVID era to plan and hope for the best while getting prepared for the worst,” said Diane Meier, M.D., director of CAPC, in a recent webinar. “It’s the same thing we say to patients and families, and we should be saying this very thing to ourselves. Maximizing the likelihood that our programs will survive through this financial crisis for health care will take developing a strategy for planning forward with practical and feasible steps.”


Careful revenue cycle management will become increasingly critical as the economic fallout of the pandemic proceeds. Roughly 30% of palliative care income stems from fee-for-service billing, with smaller amounts coming from sources like private Medicare contractors and philanthropic funding.

Two-thirds of providers rely on outside sources such as employers, hospitals, health systems and hospices to support palliative care staff teams, according to data from the CAPC National Palliative Care Registry.

Heavy reliance on outside funding sources amid pressures resulting from the COVID-19 pandemic have many palliative care providers concerned about their long-term financial sustainability. Essential planning steps to survive uncertain times of palliative care viability include maximizing revenues and minimizing expenses, according to Meier.


“A lot of this is under our control,” said Meier. “We can demonstrate stewardship on both the expense side of our palliative care services and on the revenue side. On the expense side, we can be more accountable for operational efficiencies, making sure we are making the highest and best use of precious human resources, our teams. On the revenue side, we can make sure we are maximizing fee-for-service billing and simultaneously seeking alternative payment and income sources. These are essential forward planning steps to ensure that our resources are sustainable.”

Providers can learn to maximize earned revenue from billing sources such as private insurance providers and fee-for-service Medicare. As payors, including Medicare, increasingly favor value-based payment arrangements such as Medicare Advantage, providers have responded by reshaping their models of patient care to better align with those stakeholder interests.

While providers will likely benefit from continuing to pay close attention to their fee-for-service billing, Meier advises them not to overlook opportunities to bolster income through programs such as Medicare Advantage.

“Most of us are leaving a lot of fee-for-service money on the table, and we can’t afford to do that anymore,” Meier said. “This is understandable, given a complicated, obscure and confusing payment system. The palliative care field has been hesitant to wade into the contracting world, but if there was ever a time to consider payment options outside of fee-for-service billing, now is that time. Medicare Advantage is rapidly taking over fee-for-service, and an increase in early retirement due to economic downtown [during the pandemic] may bolster enrollment further.”

Through Medicare Advantage, CMS contracts with private insurance companies to provide coverage. According to data from Avalere Health, health insurance companies such as Anthem, Cigna, Humana and United Healthcare showed growth in Medicare Advantage enrollment since from 2019 to 2020, leading to projections that plans will provide coverage to an estimated two-thirds of Medicare beneficiaries (64%) by 2028.

Despite rising Medicare Advantage enrollment rates, palliative care providers remain concerned about ways to ensure sufficient payment among unclear flexibilities in billing and coding for their services.

Meier recommended keeping open lines of communication between leaders and their organization’s coders and billers, as well as routinely checking policy announcements from their local government agencies and private payers to ensure compliance and appropriate billing for services rendered to patients.

“If leadership is not already meeting with coders, billers and auditors on a quarterly basis, then begin now,” Meier recommended as a step towards palliative programming sustainability. “Ensure you are measuring your patient encounters, both time-based and evaluation of management, appropriately. Are you using documentation templates that support the highest levels, the highest and most appropriate levels, of coding and billing? And do you have [electronic health record (EHR)] templates to support advanced care planning, time-based billing, prolonged service codes, non-face-to-face billing and medical decision-making? If you make it easy on your clinicians to bill appropriately, they will do so. If it’s a hassle, if it requires more thinking, more time, more clicking, then they won’t.”

Another strategy that palliative care providers can employ while riding out the pandemic’s financial impact is building efficiencies to minimize expenses. Rising personal protective equipment (PPE) prices and increased technology costs with expanded telehealth utilization has financially strained many organizations. Offsetting these and other pandemic-related costs will include improving operational efficiencies in staffing and patient management.

Even amid these financial pressures, workforce mental and physical health has become increasingly important during the pandemic. Support from leadership on matters such as anticipated paid time off needs, free and confidential counseling support, along with peer-to-peer virtual support have become routine for many organizations.

“We need to assume people will need to take time off, vacation and sick time. We need to make sure we aren’t understaffing, but instead overstaffing,” Meier said. “We’ve seen the power of peer support and making people feel seen, recognized, understood, valued, and supported. The way we need to do that is by operationalizing that support as a routine, not as something that only comes up when there’s a crisis, but something that occurs once a week.”

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