HOSPICE ADMISSION VIOLATIONS

Unfortunately, we have heard of alleged admissions into Hospice for inappropriate reasons. The law specifies Medicare criteria for Hospice. Cases in which the ward does not meet Medicare criteria should be investigated for Medicare fraud, cause of death, and motive for hospice admission.


To ascertain whether or not your loved one who was inappropriately placed into Hospice, please read the information below.

Medicare-Paid Hospice Admissions Must Meet Defined Criteria

An attending physician and the hospice doctor must both certify that the beneficiary’s illness is terminal and that individual has no more than 6 months to live; and provide a specific prognosis accompanied by clinical information or documentation supporting their position.


The beneficiary or his/her representative must agree to and sign an election statement choosing the Medicare hospice, and agree to waive curative care.


There must be a specific hospice plan of care which is reviewed periodically. It must include an assessment of the patient’s needs, address the management of discomfort and symptom relief, and state in detail the scope and frequency of services needed. The plan must be established by the attending physician, the medical director or physician designee, and an interdisciplinary group.

Criteria For Eligibility for Medicare Hospice Benefit for Wards with Dementia


Alzheimers, Stage 7 or beyond according to the FAST scale defined as 

FAST = Functional Assessment Staging Scale

7... severe Alzheimer's

Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up.

Plus one of the following within the past 12 months:

• Aspiration pneumonia
• Pyelonephritis or other upper urinary tract infection
• Septicemia
• Multiple stage 3 or 4 decubitus ulcers
• Fever that recurs after antibiotic therapy
• Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)

The Hospice Patients Alliance has information on hospice patients' rights.  Here is their link:

http://www.hospicepatients.org/hospic43.html

The federal law regarding hospice admissions may be seen below:

http://www.gpo.gov/fdsys/pkg/FR-2008-06-05/pdf/08-1305.pdf

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Centers for Medicare & Medicaid

Services

42 CFR Part 418

[CMS–3844–F]

RIN 0938–AH27

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