Hospice election status pilot initiative: A brief overview

August 1, 2022
Categories: Home health, Hospice, Palliative care
Reading Time: 4 minutes

As many hospice organizations know, there are often several days or weeks between when a Medicare Part A beneficiary with Part D coverage elects hospice care and when the beneficiary’s Part D plan is made aware of the election. This delay in notification can have serious effects, including causing the Part D plan to continue paying for prescription drugs that would normally be covered under the hospice benefit.

How can our industry reduce this delay in notification of hospice election? In this blog, we discuss the CMS-funded pilot test initiative designed to substantially reduce notification delays by electronically submitting the beneficiary’s hospice election status to the corresponding Part D sponsor. It proposes to do this by extracting and transmitting the hospice election status transactions from the beneficiary’s medical record using the existing 837I standard—an essential first step in this process.

MatrixCare is proud to be one of only three software vendors participating in the National Council of Prescription Drug Plans (NCPDP) Hospice Task Group to improve coordination between hospice providers and Medicare Part D sponsors to ensure appropriate coverage for prescription drugs while patients are on hospice service. By participating in this pilot test with other stakeholder groups, we’re excited to see how this project can create positive change for one of the biggest challenges among hospice organizations.

What is the CMS hospice election status pilot test initiative?

CMS has contracted RelayHealth, a Medicare Part D transaction facilitator, to design a hospice election notification system that can provide the notice of hospice election to the Medicare Part D sponsors in real-time. Receiving this notification sooner prevents the Medicare Part D sponsors from paying for drugs that may be related to the hospice’s terminal diagnosis and related conditions. The goal is to make communication and notifications between the hospice and the Medicare Part D sponsors more efficient—ultimately better coordinating prescription drug payments after patients have elected hospice care.

By sending the hospice electronic election transactions directly to the Part D sponsors, the pilot test will validate a reduction in delay of the hospice election status notification from the hospice pilot test participants to Medicare Part D sponsors from an average of 22 days to no more than 48 hours. It will likely happen in two hours or less, as it gets sent and received in real-time.

How exactly will the pilot work?

When a patient elects hospice, your organization goes through the intake process and enters information into the hospice software. Hospice software vendors that support the 837I standard for hospice election status transactions will generate the 837I file. The 837I transaction files are then sent to CMS Medicare Administrative Contractors (MACs) directly or through a clearinghouse with the notice of election information, but now what? Here is a step-by-step look at the pilot test process and how it can help reduce delay in notifications.

  • If submitting the 837I file through a clearinghouse pilot test participant, the clearinghouse performs pre-editing on behalf of the hospice provider, creating a copy of that transaction.
  • The original 837I file gets sent to the MAC for processing, while the copy goes to RelayHealth—which will perform additional edits before sending the files onto the Medicare Part D sponsors.
  • Since Part D does not work in the X12 environment, the information must be translated by RelayHealth into an NCPDP format (Nx transaction) so it can be submitted in real-time to the Part D sponsor on record.
  • RelayHealth then validates the patient transaction and routes the transaction to the Part D sponsor—all within seconds.
  • The Part D sponsor auto-responds with whether they are able to match that beneficiary record within their system.
  • A status report of the submitted electronic transactions is returned to hospice providers who participate in the pilot to show acknowledgment of accepted or rejected transactions. If transactions are accepted, the returned status report also identifies whether the patient was found in the Medicare Part D database and if found, provides the Medicare Part D plan name and contact information.

Why is this pilot project necessary?

Medicare Part D is paying millions for drugs already paid for and could be paying twice for prescription drugs for beneficiaries in hospice. This pilot test project is hoping to eliminate inappropriate Part D payments for hospice drugs that are related to the hospice terminal diagnosis or related condition and covered under the Medicare Hospice Part A benefit.

When is the CMS pilot project expected to go live?

Beginning in August 2022, RelayHealth intends to take all hospice election transactions currently being submitted by the participating clearinghouses live. Additionally, at this time, RelayHealth will begin the process of returning status reports to all the hospice provider pilot test participants. Keep in mind that this is a pilot test initiative, which means there will be room for feedback, improvement, and learning along the way for everyone involved.

What are the requirements to participate in the CMS pilot project?

To participate in this pilot project, hospice organizations are required to have the capability to generate hospice election transactions in an electronic 837I format—this is essential to creating a real-time solution. They will also need to provide contact information, a HIPAA Business Associate Agreement (BAA) and have the ability to submit electronic 837I files to RelayHealth through a participating pilot test clearinghouse (Axxess or Waystar) or have the capability to submit electronic 837I files directly to RelayHealth.

What are the benefits of participating in the CMS pilot project?

Hospice agencies that participate in this exciting opportunity will have a chance to develop an industry-wide automated, real-time solution for timely notification of hospice election data to Part D sponsors. They’ll also receive a report with notifications of hospice patients with Medicare Part D coverage as well as the Medicare Part D plan name. It takes minimal work effort to participate and allows agencies to capitalize on the existing use of 837I files.

How can hospice agencies participate?

Interested hospice agencies that meet the participation requirements can join at any time, but preferably before the August 2022 pilot go-live timeframe. These agencies should complete the implementation form along with a BAA, which can be found here: https://medifacd.mckesson.com/Hospice/Hospice-Providers/. The completed documents are to be submitted to: [email protected].

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Carolyn Dean
Carolyn Dean

Carolyn Dean joined MatrixCare as the Regulations Compliance Manager in 2014. She is responsible for monitoring CMS Medicare and Medicaid regulations in the post-acute care space to ensure company product and service solutions support compliance with new and changing regulations. Possessing over 30 years of healthcare IT experience in diverse leadership roles inclusive of customer service, quality assurance, and regulations, Carolyn has established a vast network of industry connections with various federal, state and industry entities and organizations.

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