Numerous hospice agencies are dealing with denials due to a prevalent medical review issue, specifically related to the Hospice Election Statement.

The Election Statement was updated in October 2020, emphasizing the inclusion of three specific components.

CMS has very specifically outlined the requirements that hospice agencies need to follow in order to update their election statements. However, several agencies are not following these guidelines. In medical review, repeated denials are being observed due to the absence of these three specific elements that were outlined in October 2020.

Information Needed to Contact BFCC-QIO

The first requirement pertains to providing patients with the necessary information to contact the BFCC-QIO if they disagree with the content of the election statement addendum. Patients cannot be expected to find the contact information on the BFCC-QIO website for their location on their own. This information must be clearly included in the election statement. Additionally, the election statement should inform the patient of their right to request the election statement addendum, which outlines items, services, or drugs deemed unrelated to the terminal condition and related conditions, resulting in non-coverage by the hospice.

It’s now mandatory to include a statement affirming not only the treatment of the patient’s terminal condition, but also asserting that the terminal illness and related conditions are exceptional and unusual, and that the hospice should be providing virtually all necessary care needed by the individual. Some hospices have disregarded that CMS was very specific with the language they chose. Hospices can submit appeals when facing denials due to specific wording omissions in the election statement, however the associated costs can be exorbitant, both financially and in terms of time spent with staff and potential loss of income, particularly in Targeted Probe and Educate situations until the appeal process is resolved. Therefore, it makes sense to update the language to align exactly with the requirements specified.

Cost Sharing

Additionally, another newly confirmed requirement in the election statement for October 2020 is that cost sharing needed to be addressed. Instances of denials and disputes in medical review have arisen when agencies omitted any mention of cost sharing, even if they did not plan to impose any financial burden on the patient. It is strongly recommended that hospice agencies include a statement about financial responsibility and that the patient has been provided with details regarding any such responsibility.

Election Statement to Patient in Timely Manner

Finally, there has been significant controversy surrounding the addendum and the update for October 2021, particularly concerning reimbursement. In terms of conditions of payment, it is essential to confirm that the document was provided to the patient in a timely manner. Medical review challenges have occurred as well in instances where there has not been mention of the attempts made to obtain a signature. Hospice agencies that are fighting a medical review battle because attempts to obtain a patient signature were not documented on the election statement addendum, are not included in the condition of payment. In regard to compliance, agencies could run into issues with state surveys. However, to ensure payment, agencies simply have to document the date when the election statement was furnished to the patient and ensure it aligns within timely guidelines.

The election statement issue is escalating in hospice medical review nationwide. Should you require assistance with updating your election statement or having it reviewed, please feel free to reach out to us.

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