Hospice and EMS

[tcripp]

This thread is specifically for US as it relates to medicare payments for hospice.

I ran a pt the other day for abdominal discomfort - it was clearly indicated that the pt was under hospice care. The discomfort was coming from zero BM x 8 days and had nothing to do with the reason for being on hospice in the first place. Time of day was late in the evening and when the spouse spoke to hospice, was advised to give the pt stool softeners/pain meds and to call in the morning; obviously this wasn't an acceptable option. Based on the presentation of the pt, we transported to the closest available facility. Pt got relief and returned home the next morning.

Based on your knowledge/experience, did we jeopardize the pt's hospice payments/program because of this trip to the ER? Does it negate hospice as far as medicare is concerned?

I'm trying to do some reading, but am hoping someone has some insight...

Toni

[island emt]

Ran a call the other night for one of our regulars who is under hospice care for his stage 4 Alzheimer's and big cardiac hx.

we have been there quite frequently to give a lift assist , but this night his major problem was severe dehydration and vomiting which was causing an arrhythmia and triggering his AICD .

I could have chosen to wait while we got in touch with the hospice folks : or we could provide him with the care he needed. IV started wide open and O2 along with anti emetic and we took him to the ER for further care.

I don't really care if the hospice folks get their knickers in a knot, the Pt had an issue that we could help resolve and he didn't need to suffer because he was under hospice care.

Just because they are under hospice care doesn't mean they don't get emergent care provided .

Don't know what it will do to the billing issues , and frankly I don't really give a damn.

[ERDoc]

You may not give a damn about the billing issues, but the pt's family might. They are soon going to be planning and paying for a funeral and now have medical bills on top of it.

tcripp, I don't know the answers but I don't think it will affect medicare paying the bills. As island stated, just because they are on hospice does not mean that they don't get treated. The best thing to do is to ask the pt what they want done.

[Eydawn]

Hospice usually figures it out in my experience. If you need to call, you need to call...

What we do here at my facility is call hospice first, and they send us an on-call nurse or advise us on what to do next. If it's an issue that is seriously jeopardizing patient comfort/causing distress that we can't handle, and the hospice nurse can't get here to implement their interventions, they'll tell us to call 911. They then call the hospital to let them know a hospice pt. is enroute and what their care orders state. I've had the hospice nurse be here and call EMS themselves (pulmonary edema/fluid overload, difficulty breathing, needed CPAP) and then tell EMS where to take the patient (usually to the hospital that has the inpatient hospice wing). Sometimes it's a transport for direct admit, sometimes they go by way of the ER first- varies by situation.

Occasionally, you can't get ahold of hospice, so you follow your best judgment. I've never seen someone get dropped or have non-payment for hospice services because they were transported by EMS. At least, I've never heard of it happening... doesn't mean it hasn't, but usually hospice services can document why the family/facility felt a need to call EMS for intervention so it's not a problem.

Wendy

CO EMT-B

[Just Plain Ruff]

In the area I used to work at, unless hospice called the ambulance the call would not be paid for by insurance or medicare.

I think that if the patient is on hospice then it's hospice's ball game.

I wouldn't be worried about the insurance rigamarole but ERDoc is absolutely correct. The patient might care which of course plays directly into my level of caring. IF the paitent wants to go to the ER then there it is, that's just what happens. I have in my history, made several hospice nurses angry.

But Eydawn also is correct, Hospice usually works this stuff out.

I do disagree to a point about emergent care. This might sound callous and negative but to get on hospice you have to be in the final stages of dying right? I only use my grandfather as my personal experience. We went with hospice when he was about 3 weeks away from passing. He had several illnesses that hospice treated in the hospice hospital yet would have been transported without hospice being in the mix. So if they code, are we going to work them? If they have a heart attack, do you treat that? They are already dying, isn't by providing advanced cardiac treatment, is that ethical or morally right to do?

I am just putting this out as a alternate viewpoint based on how we treated my grandfather in his last days.

If the patient wants to go to the ER and get treated, that's one thing but to take them in because a family member wants them to go (been there transported that), is that right?

[crotchitymedic1986]

The ambulance bill would not be paid by Medicare, so it would fall on the family or the hospice company.  Most hospice companies have a contract with a non-emergency ambulance service that has discounted their rates.  This usually comes about when someone is in hospice, and the family decides to pull them out of hospice (if they are in a true hospice building, not their home) and wants them moved to a nursing home or home.  So if possible it would be best to get hospice on the phone and ask if you should transport or would they like to send their contracted ambulance to handle the transport.

In any situation at home where the family is demanding transport (with or without hospices consent) or it is a "pseudo or real" emergency, I would transport and let whoever worry about the bill.  I am there for the patient, bringing up billing issues just sets you up for problems.  Its my job to treat, someone elses to collect or pay the bill.The whole purpose of hospice is to reduce the amount spent on the last month of life because that is when the vast majority of health care dollars are spent, usually needlessly (I think the statistic is like 25% of every Medicare dollar is spent on the last month of treatment for dying patients)

Edited September 7, 2011 by crotchitymedic1986

[ERDoc]

http://www.medicare.gov/publications/pubs/pdf/hosplg.pdf

http://www.medicare.gov/publications/pubs/pdf/02154.pdf

Refer to the bottom of page 7. It sounds like this will probably be covered, depending on the pt's reason for being in hospice.

[scubanurse]

With my recently passed grandmother who was in hospice, when she stopped eating and became comatose, they asked if we wished for her to be brought to the hospital. We instead chose palliative care in her nursing home room. I don't understand why the facility's hospice nurses couldn't have given a laxative PR or an enema to relieve their pain. My grandma had a similar issue but didn't seem to be in any discomfort abdominally from it and was receiving PO MS anyways.

I doubt you compromised any part of their hospice program with Medicare....

[tcripp]

You may not give a damn about the billing issues, but the pt's family might. They are soon going to be planning and paying for a funeral and now have medical bills on top of it.

tcripp, I don't know the answers but I don't think it will affect medicare paying the bills. As island stated, just because they are on hospice does not mean that they don't get treated. The best thing to do is to ask the pt what they want done.

The patient wanted relief if it meant going to the hospital. We also returned the patient after the call and the serenity on his face was priceless. I know I did right. But...I'm wondering if we should have called hospice back to advise that we were transporting. Or, do we advise the patient/family that this "could" affect payment so they can make an informed decision. (I don't like that the gov't has this separated...it sucks.). That's why I'm trying to find out just "what is".

I don't understand why the facility's hospice nurses couldn't have given a laxative PR or an enema to relieve their pain.

Not sure I understood why either.

[ERDoc]

The patient wanted relief if it meant going to the hospital. We also returned the patient after the call and the serenity on his face was priceless. I know I did right. But...I'm wondering if we should have called hospice back to advise that we were transporting. Or, do we advise the patient/family that this "could" affect payment so they can make an informed decision. (I don't like that the gov't has this separated...it sucks.). That's why I'm trying to find out just "what is".

Not sure I understood why either.

I agree with you. My statement about not giving a damn was directed at island, not you. I'm sorry if it sounded like I was talking to you that way. It sounds like you did the best you could. The world of medical billing is a world all of its own that even the people who make the rules don't fully understand. To expect a medic in the field (or even a doctor in the ER) to understand it is crazy. In the end, it's not you that is going to cost the pt anything, it is theirs or their family's decision.