Ensuring Medicare Eligibility Key to Hospice Revenue Cycle Management

Challenged with the intricacies of insurance billing along with evolving policy changes and increasing regulatory scrutiny in recent years, ensuring patients’ Medicare eligibility has become vital for hospices’ bottom lines. Effective processes, valuable staff and external resources are some of the key components for providers to consider as they seek to avoid lost revenue associated with billing and documentation errors.

Maintaining an effective revenue cycle management process involves a hospice carefully determining and documenting a patient’s eligibility for the Medicare Hospice Benefit.

“Health care reimbursement can often be difficult,” said Matt Zaboltony, vice president of revenue cycle services at Pittsburgh-based health care software company Net Health, in webinar. “Ensuring Medicare eligibility as part of your hospice practice is incredibly important, and this is definitely an issue that we see many providers struggle with quite often. There’s no ‘easy button’ when it comes to managing reimbursement in hospice. Developing a process around this component of your business is very important.”


Hospices have been coming under extensive regulatory scrutiny in recent years from U.S. Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health & Human Services Office of the Inspector General (OIG). Much of the regulatory, and sometimes legal, action taken by CMS or OIG are audits spurred by poor or incomplete documentation of a patient’s hospice certification, with providers facing Medicare claim denials, slowed payments or lost revenue as a result.

Careful billing and revenue cycle management have been critical in preventing errors that could lead to CMS audits. Ensuring staffing expertise, training and accountability are key components to improving upon billing errors, according to Zablotony.

“Even having a basic understanding of Medicare and insurance can really go a long way in helping to ensure that practices are functioning properly and you’re getting reimbursed for everything that you need,” Zablotony said. “You might have administrators who understand part of the process, but not all of it and documenting that process can ensure training and retraining of staff. Verification of benefits, ensuring that the patient has coverage, knowing if there is a prior authorization, you need people to help you manage all of that and help supplement your current operations.”


Staffing levels and training impact revenue cycle management. Hospices need a workforce that can handle both the capacity of incoming patient volumes along with ongoing CMS billing policy changes, in addition to having specialized knowledge of compliance and insurance billing best practices. Clearly defining staff roles and responsibilities is critical for hospice leadership as they work to improve billing set up for new and transferring hospice patients. Designing a process around best billing practices starts at the beginning, when a patient first comes on to service.

“Hospices can benefit from designing a process managing the ‘front end revenue cycle functions’ such as patient intake, eligibility and benefit verification, and any prior authorization requirements important to billing set up,” said Zablotony. “Verify that the patient is covered under Part A instead of billing assuming this is part of the patient’s coverage. Ensure you’re identifying whether the patient has other insurance coverage that may impact your Medicare reimbursement, such as having Medicaid as a secondary benefit or having private insurance to properly set up the billing to send the claim to the appropriate payer and in the appropriate order. Design a process around managing these components.”

Ensuring a streamlined billing process and accurate documentation will remain a top priority for hospice providers as they strategize ways to minimize the financial hits and improve patient care delivery.

“The first most important part of hospice business is making sure you’re providing good care,” said Zablotony. “The second is making sure you’re getting paid. When it comes to seeking and identifying coverage for your patients, you want to make sure you’re doing this quickly and aggressively.”

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