Liability for Payment:
Covered and Non-Covered Expenses
Normally, families of hospice patients would not be receiving
bills for hospice services since hospices receive reimbursement
for those covered hospice services from Medicare or private
insurance. However, in some instances, families of hospice
patients are receiving bills, and they are often confused by
these bills. In certain cases, the bills are actually improper
and are attempts by a hospice to get paid twice for the same
services (fraud). Sometimes the bills are completely proper.
Families ask whether or not they have to pay for these bills
relating to services, equipment, medications, or other items
provided to their loved one.
Services, equipment, medications and other items fall into two
main categories which need to be understood: "Covered
Services" and "Non-Covered Services."
Hospices are responsible to pay for the expenses of all
covered hospice services out of the reimbursement they receive
from the Medicare program or other insurance company For
example, the hospice itself must pay for all medications which
are used to manage symptoms which are due to the terminal
illness. The hospice may charge a small co-payment of up to $5.-
per prescription.
Any covered services which are included as part of hospice
can not be billed to the patient or family by a hospice. If
the hospice did so, and some "rogue" hospices are doing
so, that would be health care fraud. Why? Because it would amount
to billing twice for the same set of services: getting paid by
Medicare or another insurance company first, and then getting
paid again (for the same services) by the patient and family.
Hospice Billing Others for Covered Services Is
Prohibited
The Medicare Hospice Manual, Publication 21, chapter 4,
reimbursement for hospice care states at Section 411:
"Section 1866 of the Social Security Act requires
providers (including hospice providers) to file an agreement with
the Secretary of Health and Human Services in order to be
qualified to participate and to be eligible for payment under the
Medicare program. In this agreement, the hospice
agrees not to charge (and accordingly may not charge) any
individual or any other person for items or services for which
the individual is entitled to have payment made under the hospice
provision. .... a hospice may not bill a third
party such as an insurance company ... for covered palliative
drugs and biologicals for which payment is made through the
Medicare rates."
"If a hospice furnishes, at the request of
a beneficiary, items or services in addition to those
that are covered under the hospice provision, the
hospice may charge the beneficiary for these items or services.
[emphasis added]
Written Notice Required Before Services Provided
A hospice must provide written notice to the patient and
family before providing any service that the hospice intends to
charge the patient and family for. And, the hospice can only
properly bill for services which are not covered under the
hospice benefit. This means that if the hospice wishes to bill
you for any noncovered services or other items, it must truly
inform you (and do so in writing) that it will charge you for
those services, before the service, equipment or
other item is provided.
Even if the hospice inaccurately tells you that the service is
"not covered" (and therefore they claim that they can
charge you), and it actually is covered, the hospice still has to
provide written notice to you beforehand that they intend to bill
you for the service. Then, you would have, in writing, a notice
that they would be billing you for services which are covered and
for which they are not allowed to bill. So, hospices that are
improperly billing for actually covered services do not normally
provide written notice beforehand that they intend to bill you;
they just send a bill and hope to get paid by you and Medicare as
well! In any case, a hospice cannot "surprise" you
after the services, equipment or other items were provided and
just send you a bill "out of the blue" without
providing written notice beforehand.
The Medicare Hospice Manual from the Health Care Financing
Administration (HCFA) Publication 21 states:
Chapter 2, Eligibility and Coverage, Section 274.1,
"Notifying Patient of Noncoverage"
"If you are aware that the services furnished a patient are
not covered, advise the patient (or his representative) in
writing prior to or at the time of start of care (or at the time
the type of care changes) that the care is noncovered and that no
claim for Medicare reimbursement will be submitted."
If you have questions about any bills you receive for hospice
services, first try to determine if the services, equipment or
other items are "covered" services or not. If the bill
is for hospice services which are definitely covered under the
Medicare or insurance benefit, the hospice is not permitted to
bill you for those services! You may wish to contact the
hospice's billing staff and hospice director to discuss the
bill.
If the hospice insists that you pay for services which are
part of the hospice benefit, even after you question those
charges, you may wish to file a complaint to the U.S. Office Of
Inspector General. See Links to Report Fraud.
Note: this information is provided here due to complaints the
Hospice Patients Alliance has been receiving from the public
about hospices that actually are improperly billing them for
covered hospice services.
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