Questions over which services are deemed related to patients’ terminal diagnosis in hospice care are crucial, and physicians’ determinations of those factors may be growing more complex.

Medicare Conditions of Participation (CoPs) allow health care providers to receive payments for services and items that are considered unrelated to a hospice patient’s terminal illness and related conditions.

Though allowed, payments outside the Medicare Hospice Benefit should be “exceptional, unusual and rare,” according to the U.S. Centers for Medicare & Medicaid Services (CMS). CMS has taken a stance that essentially all the care needed by a terminally ill patient should be covered through the benefit. However, that is not always what happens in practice.

One contributing factor may be some confusion regarding the regulations, according to Dr. Edward Martin, chief medical officer for HopeHealth.

“CMS is using the old language talking about terminal diagnosis and related conditions, because it’s not just that. It’s really a condition that’s contributing to their terminal prognosis. If a patient has severe heart failure and moderately severe COPD, we’re going to have heart failure first,” Martin told Hospice News. “COPD is not a related condition, but it definitely contributes to their prognosis and so we’re responsible for those medications and interventions. I think that creates some confusion.”

Another factor is the high cost of some medications that patients may need, but the hospice can’t afford, Martin said. Sometimes patients can be switched to a cheaper medication or it may be deprescribed, but that too can be an involved process, he said.

These “unrelated” payments have been soaring. Between 2010 and 2019 Medicare paid a total of $6.6 billion to non-hospice providers for services provided to hospice beneficiaries, according to a 2022 report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG).

These rising costs led to a recommendation from OIG that CMS study whether hospice reimbursement reform is needed to address duplicate payments.

Hospice physicians are responsible for some of the most important aspects of care. These include determinations of patients’ eligibility, the level of care they need, prognostication, determination of relatedness to the terminal condition and medical management of the patient.

False Claims Act (FCA) cases have also been on the rise in the hospice space, often involving issues related to patient eligibility for the benefit. Repercussions have been heavy for hospice providers, with some facing hefty fines, criminal charges, or prison sentences. Other individuals have been barred from practicing altogether.

When considering relatedness, physicians must take a holistic approach, according to Dr. Lauren Templeton, hospice physician consultant at Weatherbee Resources and Physician Council member at The Pennant Group (Nasdaq: PNTG).

“The intent [of the regulation] is for us to provide holistic care, virtually all the care that our beneficiaries need that is medically necessary. So we have to start within that framework,” Templeton told Hospice News. “From there, we’re looking at pathophysiology, and that’s why it’s the role of the physician to determine if something is related or unrelated. But it’s not just as simple as saying ‘the heart and the lungs mix together, and that’s why they’re related.’ We also have to look at the impact on our patients, the burden of the disease, and whether something causes extreme symptoms, whatever the diagnosis might be.”

CMS rules allow patients to request an addendum to the hospice election statement that details what conditions, medications or services are related or unrelated to the terminal condition. However, these requests are very rare, according to Martin and Templeton. Hospice News spoke with Templeton and Martin at the National Alliance for Care at Home’s Annual Meeting in New Orleans.

When the agency disagrees with a hospice’s determination, it will likely lead to payment clawbacks, often in the form of a demand letter, Templeton said. It can also lead to provider audits.

In most cases, hospices should err on the side of considering conditions related, when possible, for the sake of their patients, Templeton indicated.

“If it’s impacting the plan of care for our patients, that would make it related for us,” Templeton said. “That’s the part that I’m most excited for hospices to enter in on, because that just further makes progress in individualization of the plan of care. And that results in better care for our patients.”