This transcript has been auto generated
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond where we connect you to what matters in the ever-changing world of hospice and palliative care. Hospital to Hospice: Managing Referrals and Relationships. Bryan, this is an exciting episode because it is a listener request. So here we are. We got an email from a listener who was a “I'm a big fan of your Hospice Insights podcast” and then proceeded to ask us to speak about, GIP eligibility at the end of hospital stays.
00;00;48;13 - 00;00;59;16
Meg Pekarske
And, what does that look like and where the lines and stuff. So here we are today talking about this listener question, so
Bryan Nowicki
Yeah, it's great.
00;00;59;22 - 00;01;10;04
Bryan Nowicki
Great to get feedback from listeners. And we do take requests. So yeah, happy to to address the topics that are on folks minds though. And this is an interesting one.
00;01;10;11 - 00;01;24;23
Meg Pekarske
Yeah. So it sounds like request I feel like we're Casey Kasem like doing our own like what was that came out? It was on the weekends with Casey Kasem.
00;01;24;25 - 00;01;26;25
Bryan Nowicki
The American Top 40. Yeah.
00;01;26;27 - 00;01;38;18
Meg Pekarske
They did the hits. Yeah, they mean the hits. So I think we're showing our age. They're only like Gen X and greater that know that reference probably.
00;01;38;20 - 00;01;45;06
Bryan Nowicki
Yeah. Who took over for, for Dick Clark, and now he's the younger guy, Ryan Seacrest. Yeah, for the younger.
00;01;45;07 - 00;01;58;22
Meg Pekarske
Probably now our aged. But he did seem younger at the time, so, so anyway, we're rolling the hits here, taking special requests and dedications. Dedications? That’s what I'm thinking.
00;01;58;22 - 00;02;00;16
Bryan Nowicki
This is a long distance dedication.
00;02;00;17 - 00;02;35;09
Meg Pekarske
Yeah, exactly. A long distance dedication to our listeners here. But, so. And I guess when I read this question, Bryan, a couple things that struck me, and we'll break down each of them, but one is just let's take a look at what the government has actually said about what qualifies for GIP, because I think this is actually an area where there are some very helpful and very specific guidance.
00;02;35;12 - 00;03;09;27
Meg Pekarske
And I want to make sure that hospices are not being too conservative or because I think there's been audit activity in the space and people getting very nervous and very conservative sometimes, and maybe too much so because obviously, Bryan, you can speak to your audit experience because we've taken a lot of cases to ALJ involving GIP, including one that was like many, many, many, many, many millions of dollars.
00;03;09;27 - 00;03;44;25
Meg Pekarske
And we want, you know, all of those, so so let's break down what the government actually says qualifies for GIP. And then two, I think talking about, these questions often come up because there is late referrals to hospice. And so how can we work with our hospital partners to say, you know, can I can we work together to, you know, get patients at the right time?
00;03;44;28 - 00;04;06;09
Meg Pekarske
Because a lot of patients, as we know, do want to be able to die at home, if at all possible or at a minimum, not die in the hospital setting. And so how do we essentially deal with this more on the front end. So we're not getting late referrals. What I don't want to get into a ton.
00;04;06;12 - 00;04;43;16
Meg Pekarske
But it's a question that comes up a lot. It's just I think to nuance for a podcast is just when do you do the routine home care level of care in the hospital? I mean, those are should be rare instances that we're doing that, not like a, you know, regular thing, but I've come to glean over the last ten years, that those issues have been coming up more, and so if you do have those issues, that's more of a we'd need to talk offline, about those.
00;04;43;16 - 00;05;06;12
Meg Pekarske
So just as a disclaimer, we're not going to get into that area. But let's kick it off, Bryan, first with what is the government actually say about what the standard is for GIP eligibility? Because, it is it has some very specific things of when it might be appropriate that are relevant to this question.
00;05;06;15 - 00;05;30;18
Bryan Nowicki
Yeah. So CMS, the standard is, is pretty generally stated, and I think CMS has made some comments in its manuals that, may come as a surprise to some providers in the breadth of GIP. A GIP is one of those. It's a level of care where CMS, they, they audit folks who provide GIP for more than six days.
00;05;30;24 - 00;05;55;11
Bryan Nowicki
They criticize hospices for not providing enough GIP. It's easy to get caught in the middle of really what, what should the hospice be emphasizing? But I think the place to start really is what are the requirements? GIP is, inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings.
00;05;55;13 - 00;06;22;15
Bryan Nowicki
So kind of fill in that in working with your physician about how do you demonstrate that. And CMS has given a couple of examples that I think are pretty helpful, including one that relates to this topic we're talking about this hospital to hospice issue. So if you go to the benefit policy manual, CMS has given an example of what that could be a an appropriate GIP, GIP stay.
00;06;22;18 - 00;06;50;00
Bryan Nowicki
And what they say is that a brief period of general inpatient care may be needed in some cases, when a patient elects the hospice benefit at the end of a covert hospital stay. And so in advocating these cases, if we have a patient, who has come off of a hospital stay, admitted to the hospice for GIP, and we're for some reason that claim was denied.
00;06;50;02 - 00;07;13;13
Bryan Nowicki
We're pointing that out to the decision makers in the appeal process is this falls right into what CMS has identified as kind of a classic example of the appropriateness for GIP. And the documentation should reflect that. I mean, it's going to be clear from the documentation that this patient was in the hospital and then, went into GIP at the hospice.
00;07;13;13 - 00;07;38;14
Bryan Nowicki
But draw those connections in the documentation yourself. So have they don't talk to your physicians, nurses, clinicians about drawing that connection between the covered hospital stay and getting on to dip. That that's very helpful, very persuasive. When we can point to CMS’s own manual as supporting our position data. And another element or example.
00;07;38;14 - 00;08;07;02
Meg Pekarske
Bryan, maybe just to pause there. It sounds like judges in the cases that you've had, you know, that is helpful. I mean, we've won a lot of GIP cases. And I think when we're evaluating the relative strength of GIP, obviously the devil's in the documentation, but in terms of just from a pure data perspective, it's like, are they coming out of a hospital stay?
00;08;07;02 - 00;08;32;06
Meg Pekarske
Because again, that's like knowledge scenario where it might be something that's needed because they they specifically say to in the manual that it's not equivalent to a hospital level of care. So the fact like they're not going to be in the hospital anymore, does it mean like, well then they don't qualify for GIP because they're not qualified to for the hospital level of care anymore?
00;08;32;06 - 00;08;56;22
Meg Pekarske
It's sort of a different kind of thing. And, and there can also I mean, sometimes folks are actively dying and not I'm not saying every actively dying person needs GIP. I don't want anyone. I just has to think that we are saying that. But there can be a lot of changes that are going on at that period of time.
00;08;56;22 - 00;09;25;01
Meg Pekarske
And I think the kind of but in medications people might have been getting in the hospital could be different than the things we might be doing. And so there's a lot of adjustment that might need to be happening as they are transitioning to our care and things like that. So, when we, you know, back to what you read in the benefit, policy manual is, you know, for pain control or acute symptom management.
00;09;25;01 - 00;09;59;07
Meg Pekarske
And it was like, and I know we're getting here, but other examples are the need for medication adjustment. So I know when we're advocating for GIP cases I also look at how many med adjustments did we need to make like every single day. You know, we're titrating medications were, you know, we were, doing a lot of potentially PRNs because we're trying to understand, you know, what's the, the the right amount before we move to scheduling something.
00;09;59;07 - 00;10;33;02
Meg Pekarske
And so medication adjustment is another thing. And then observation. Holy cats, Bryan. Observation. You know, that's that's as you said, very broad. Two and again, I don't think Bryan were advocating like, everyone coming out of a hospital needs to be a GIP for observation. I mean, that's not what we're talking about, but, you know, we're going to the benefit policy manual.
00;10;33;02 - 00;10;45;05
Meg Pekarske
And, Bryan, we should maybe post this in the episode notes so people can have this as a reference point, because it is good to read CMS’s own words at this.
00;10;45;07 - 00;11;12;05
Bryan Nowicki
Yeah, absolutely. And that that observation note when CMS says, you know, if a patient is in need of medication adjustment, observation or other stabilizing treatment, again, that CMS words and we like to to argue that we are doing exactly providing exactly the kind of care that CMS is expecting will be provided at GIP and for observation. We try to frame it as skilled assessments.
00;11;12;07 - 00;11;56;17
Bryan Nowicki
What kind of assessment is being provided for that patient that could not be provided in another setting, because that's that final critical element that it ALJ often ask about at the end of testimony from an expert, they'll say, well, why couldn't all of this have been done in a different setting? And so we want to be able to say, well, you know, it was in only in GIP where there was ready, frequent, you know, immediate access to nurses who are trained in how to assess patients clinically and determine what additional interventions may be needed, even if no interventions are ultimately provided, or if no interventions are kind of provided with a degree of frequency that
00;11;56;17 - 00;12;30;23
Bryan Nowicki
suggests, you know, it's equivalent to hospital inpatient care, which, as you said, it's not. But as long as we can make the argument that this patient needed to be assessed in a professional way to determine if they're, you know, have they reached a level of stabilization, is a is it a kind of stabilization, stabilization that is going to endure, or would it be irresponsible to discharge a patient quickly upon the first whiff of potential stabilized ation, without allowing them know the opportunity to make sure that it's going to endure?
00;12;30;23 - 00;12;37;28
Bryan Nowicki
They're out there in the clear. They can then go home and ideally, have a peaceful death in the home.
00;12;38;00 - 00;13;19;06
Meg Pekarske
Yeah. Well, and and to we focus so much on the your, term nursing aspect of this, but importantly to the benefit policy manual talks about when they say stabilizing treatment such as psychosocial monitoring. That's important because again, we've like medicalized hospice so much in the role of the physician the face to pay. You know, I mean it just hey there is this psychosocial aspect of what's going on here too that is important.
00;13;19;06 - 00;14;01;21
Meg Pekarske
So, so again this is probably an overstatement, but I feel like dramatic today. This is one of the most helpful and very specific, examples, and, and guidance the government has given in the areas that, you know, they can be very obtuse and in other ways. And so there's, there's room here in terms of interpretation. And I think, you know, our audit experience says that it's not it's it's not like these things are living in practice.
00;14;01;21 - 00;14;07;22
Meg Pekarske
Like following this gives you a very good defense on the audit side.
00;14;07;24 - 00;14;29;07
Bryan Nowicki
Yeah. And I think that's absolutely right. But but what is important is in order to take advantage of what CMS has done here with some of these broad statements, is make sure your medical records reflect that. Oh, it's certainly it's harder to go back in time at an ALJ hearing and say, well, these were a skill assessments and this is what they were looking for.
00;14;29;07 - 00;14;52;19
Bryan Nowicki
Better to document in real time. What value and expertise is the nurse bringing to the situation when they're doing an assessment, they skilled assessment. You know, where is it? Psychosocial monitoring. You'll get specific in your documents so that you can later on connect the dots. Because ALJ is are going to expect you to to have a record.
00;14;52;19 - 00;15;16;22
Bryan Nowicki
It's going to they're going to expect interventions like you said, that, you know, if you don't do anything with the patient, your, with in terms of interventions, that's going to be a tough case to make. But recognize the interventions can be, you know, medications, it can be observations, it can be other sorts of interventions that you need to document in order to take advantage of them and fall within what CMS is saying.
00;15;16;24 - 00;15;45;04
Meg Pekarske
Well, and I think critical to that is this question embeds in it that work at doing GIP in the hospital. Right. Is that you can't just rely on the hospital's documentation to support your level of care, right? Like they are. You're contracting with them for that level of care, assuming the person qualifies and their documentation is going to be very important.
00;15;45;04 - 00;16;17;07
Meg Pekarske
Right. But the layer of documentation of our nurses, our social workers, are because they're going to be more attuned to the GIP level of care. And I think embedded in this question is the hospice needs to be making this determination of level of care. And that's a push pull, that I think hospitals may say, well, they qualify for GIP and we might be saying, well, that's our determination, not yours.
00;16;17;11 - 00;16;50;29
Meg Pekarske
That can be a frustrating aspect of this. So I think really critical that are nurses. And this is why ideally, you know, that you're you don't have to pass on 100% of your per diem to the hospital for GIP. I know in some areas you can't get a contract with the hospital without for something less than 100%, of the per diem, but because you're still going to have to do stuff when someone's on GIP, right?
00;16;50;29 - 00;17;20;14
Meg Pekarske
You're still sending your nurses, your social workers, things like that. And so that documentation, I think that's so critical that you're talking about Bryan, is going to be a combination of both what the contracted hospital is documenting, but also what your staff is, is writing, because they're going to be more attuned to this level of care and the standards for documentation.
00;17;20;16 - 00;17;56;05
Meg Pekarske
But but yeah, I think, again, medication adjustment, observation and other stabilizing treatments such as psychosocial monitoring. So, again, I always like to distill things down to, you know, how many adjustments are you making? And, both in the type of medication but also dosages. And I already said the PRN thing, but I think that that's important, too, because when we're just getting involved with the patient, that's going to be more apt.
00;17;56;05 - 00;18;15;16
Meg Pekarske
What we're using is and how we can figure out, you know, what's the rate. You know, right dosage to make sure that this pain is really controlled and we're not over medicating or under medicating and all that.
00;18;15;19 - 00;18;36;00
Bryan Nowicki
Yeah. Takes a lot of, from what I understand, talking with a number of physicians as we kind of go through these cases, there is a lot of tinkering with the medication, you know, and trial and error to find the right mix that's going to get that patient where they need to be to get off of GIP.
00;18;36;03 - 00;19;05;09
Bryan Nowicki
And that importance of documentation also goes with that final element. I mentioned before that the care could not feasibly be provided in another setting. A lot of times that is a piece of information that, is not really explicit in the documentation. But as I said, the ALJ are always asking that question who would be, an easier argument for hospice hospices to make later on if they documented?
00;19;05;09 - 00;19;25;05
Bryan Nowicki
Well, why couldn't we have done this in another setting? And then we're not trying to develop that answer for the first time in an audit appeal, but it's in the documentation itself and becomes a much more reliable, credible piece of information to get you through these appeals. And maybe you don't you wouldn't even get denied in the first place if that was more clear.
00;19;25;07 - 00;20;03;27
Meg Pekarske
Yeah. And so I guess on that this the second broad point is working with hospitals. Like, are we getting patients at the right, time in their care. And I think palliative care is an important bridge. And so many hospitals have their own palliative care service. If they if they don't, you know, we've worked on partnerships. Where hospices, through, you know, a separate business line or whatever may be supporting or helping manage a palliative care program in the hospital.
00;20;03;27 - 00;20;33;22
Meg Pekarske
But, I think is at bridge here having that really important goals of care conversation with family members, like, is that happening at the right time or is that happening really because no one wants to have the conversation when it's so late in the in, in the game. And so I think that that's part of these conversations too.
00;20;33;22 - 00;21;02;14
Meg Pekarske
Are we getting patients at the right time? And I do think, through personal experience, I used to think like, oh, if we can only provide a day of, of hospice care, like because hospitals will say, oh, I gave you the referral because then they can get, you know, their 13 months of bereavement and all this stuff and like, well, how much can we do in 24 hours?
00;21;02;14 - 00;21;25;18
Meg Pekarske
And I do think hospice can do a ton in 24 hours. As a, person who's experienced the gift of that, but it's not always ideal. Right. And so, so I do think we can do a lot, but we can do it even more when we have 48 hours and, you know, 72 hours and and all that.
00;21;25;18 - 00;21;52;05
Bryan Nowicki
So, yeah. And I think that's where, you know, if tensions arise between the hospital hospice relationship, it's usually, when there's a rush to accomplish certain things or everybody has their competing interests and they're trying to accomplish that in a relatively short amount of time. The hospice wants to, transition care to a hospice. The hospice certainly wants to get in there and provide the care.
00;21;52;08 - 00;22;14;26
Bryan Nowicki
The patient, wants to die. Have a good death. Comfortable setting. Probably not in a hospital. Definitely not in a hospital, but at home. And so what you're saying, Meg, about, you know, earlier access and, information about hospice, is a way to relieve a lot of that last minute tension that can arise in that relationship.
00;22;14;29 - 00;22;44;06
Bryan Nowicki
And it's, having that kind of communication and discussion with the hospital about how do we, you know, stretch out. So we're not, kind of in the last minute rush all the time and frustrating people's expectations. How do we move that back? A number of days so that it's a just an easier transition. And maybe if the hospital kind of has a better understanding of the hospice role and responsibilities, you can all get on the same page, and that's going to benefit the patient overall.
00;22;44;08 - 00;22;49;26
Bryan Nowicki
And you're not going to have those kinds of, tensions arise when it's a last minute situation.
00;22;49;29 - 00;22;58;07
Meg Pekarske
So easier said than done. So oh yeah. We're not here to be like Pollyanna. Like, oh, just do this. It's so easy, right? But just pick.
00;22;58;07 - 00;22;59;21
Bryan Nowicki
Up the phone and solve all the problems.
00;22;59;21 - 00;23;00;22
Meg Pekarske
Yeah, well.
00;23;00;24 - 00;23;01;09
Bryan Nowicki
What's the big.
00;23;01;10 - 00;23;28;09
Meg Pekarske
As you say, there's a lot of competing interests here. And, you know, you have, a hospital that has, you know, how many physicians practicing it that all handle things in a different way and all that. So, it is it is a challenging issue. But I guess the takeaway is let's go back to basics and dust off, like, what has the government said about this?
00;23;28;09 - 00;24;07;15
Meg Pekarske
And are we documenting to this standard? Because this is, you know, the standard and, and because I think, you know. This is, I guess, my personal commentary here, something I don't like to see about these audits is that people feel like, oh, I just need I'm practicing medicine in a way based on audits. And and it's like what you hear from other people and stuff because, you know, our big thing when we talk about audits is what you hear is the beginning of the story, not the end of the story.
00;24;07;15 - 00;24;33;02
Meg Pekarske
And that's why we like to share success stories, because I think it gives some perspective that all is not lost. So if you essentially, you know, practice medicine or practice, hospice in a way like I will never get audited, right? First of all, I think that's complete deeply, you know, and possible in this day and age right now.
00;24;33;05 - 00;25;05;25
Meg Pekarske
But to just because a claim gets denied does not mean that you did something wrong. And that's why there's appeals and that's why, you know, still 70, 80, 80% of claims that we appeal, we win. And so I don't want us to be so scared that we're not doing the benefit right. And good hospices should. I mean, you're you're following the law and you're following the guidance.
00;25;05;25 - 00;25;38;07
Meg Pekarske
And that should mean something. And so shouldn't bury your head in the sand. But you also shouldn't be afraid to do what the benefit allows for. Right? It's like you're right, people, when you look at the the data, I mean, I've never worked with a hospice that that had a GIP cap problem. Right. Even though the cap is written that, you know, there's a second cap for for GIP, no one's hitting that.
00;25;38;10 - 00;26;07;12
Meg Pekarske
And frankly, when you look at most of the data there isn't a lot of GIP that's being provided. I know that it's getting audited because it's a high dollar amount and they recently increase their rates, but, it is it is a really important level of care. I'm glad people are being mindful. Listeners are being mindful of audit activity in this space.
00;26;07;15 - 00;26;37;16
Meg Pekarske
I think I just want to remind people of, hey, let's actually look at what the government said about this. And, you know, if you do think this person is eligible under the guidance, like you should provide that care and you should look at it daily, right, too. This isn’t, I think that's another challenge, is, are you really documenting eligibility for GIP on a daily basis as opposed to just, you know, oh, okay.
00;26;37;16 - 00;26;41;23
Meg Pekarske
They're eligible. And then we'll look at it again in a week or so or whatever.
00;26;41;26 - 00;27;10;16
Bryan Nowicki
That certainly the expectation is daily. But but also just on the clinical side, as you mentioned, make that there's a lot of resources for making clinical judgments. And audit results is not the best resource to guide your medical practice. I mean, you know, you can go to a board, you refer to board certified hospice physicians, other medical literature related to hospice, a GIP, whatever is clinically sound.
00;27;10;16 - 00;27;37;23
Bryan Nowicki
And make sure your physicians are up to speed on the medicine around genuine patient care and acute, or pain control and acute symptom management. That's I think, the primary resource I always tell our clients when they get their order results, take it with a big grain of salt because there is an appeal process. And the, the reviewers in these audits, they're not necessarily focused solely on clinical issues.
00;27;37;26 - 00;27;58;08
Bryan Nowicki
So you shouldn't, kind of have your practice of medicine dictated by particular audit results in a single audit. But look at the bigger picture. And, you know, persistence and patience pays off in these audit appeals, where ultimately, in most cases, good medicine wins out.
00;27;58;11 - 00;28;26;18
Meg Pekarske
Yeah. And I think that to that point, making sure that your physician is very involved in terms of documentation of eligibility for this level of care, not just the nurse. Right? I mean, people get an order from a physician for level of care changes. It's very common practice and, best practice. But also that's not a one and done.
00;28;26;18 - 00;29;06;03
Meg Pekarske
I think keeping your hospice physician engaged during you're probably going to be having a physician, evaluating this patient, clinically examining them every, every day, but also making sure that the physician is being very mindful of that definition. And I think it's great when we can have physicians, be documenting to this on a real time basis, their level of care, because nurses can be documenting about, you know, the symptoms and the medication adjustment needed.
00;29;06;03 - 00;29;48;08
Meg Pekarske
But, you know, a physician can really be a connector to, why this level of care is needed. And as you said, on a real time basis. So. All right, well, we don't have any magic. I think it was just, a great question, a hard question. But something I thought that, we should address because our listener asked us to, but also that there are some helpful things to remind people from the CMS guidance, and it's not in, the, state operations manual.
00;29;48;11 - 00;30;11;20
Meg Pekarske
It's actually in the benefit policy manual, that we're talking about this. So maybe everyone knows about this, but it's always a good reminder to to folks because I think we get so focused on what the caps have to say. And yes, that's important. But this there's other manuals and this is really important information. So we will post this.
00;30;11;20 - 00;30;45;12
Meg Pekarske
And again thank you to our listener for the question. And please always, send questions or feedback or ideas or you know, hey, we really enjoy it because we've Bryan and I put a lot of time into the podcast. So hearing that you find it valuable, means a lot to us. So and you can always review us on, you know, Apple Podcasts or wherever you get your podcast and give us, you know, a great rating because it does help other people, find us.
00;30;45;12 - 00;31;11;21
Meg Pekarske
So thank you.
Bryan Nowicki
Thanks, Meg.
Meg Pekarske
Well, that's it for today's episode of Hospice Insights: The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at huschblackwell.com or sign up wherever you get your podcasts. Until next time, may the wind be at your back.