MEDICARE, MEDICAID AND PRIVATE INSURANCE
The major sources of payment for hospice care are Medicare, Medicaid and private insurance, although Medicare certainly provides for the larger segment of the hospice population. Which source of payment covers for your hospice services should have little effect on the type and quality of services you receive.
Any hospice which receives reimbursement from Medicare or Medicaid must be licensed and certified by the State agency which surveys and inspects health care agencies. If the hospice is part of a national or regional corporation, the location where the hospice actually provides services determines which State performs these inspections. Most private insurers require the hospices to meet the same requirements as do Medicare and Medicaid, and to provide the same set of services included in the standard “Hospice Benefit.”
There is an additional benefit to having a private insurance company cover your hospice services: you have an insurance company “case manager” who reviews the services needed by the patient and family, and the services being provided by the hospice. Unfortunately, in some instances, some hospices do not provide all the services you are entitled to! In these cases, you need to be assertive and speak with the RN case manager, the hospice’s director or the hospice Medical Director.
If you still experience any difficulty getting the hospice to provide adequate services, do not hesitate to call your insurance company’s “case manager.” They can “go to bat” for you to get you the services you need. If the hospice still refuses toprovide the services you need, consider switching hospices. Hospices will usually “back down” and provide what you need if you let them know that you will switch. Do not be fooled by “threats” that hospice services will be interrupted or that “it’s not possible” to switch at this time.” Nonsense. You always have the right to choose whichever physician you wish and change at any time; you always have the right to switch hospices to get the services you are entitled to! If you do switch physicians or hospices, the hospice must assure a smooth transition and continuity of services throughout the change.
Because the Federal and State governments wish to “get their money’s worth” for the funds they pay out to the hospices, it is important to report any hospices who do not provide the full set of services needed to meet the patient’s needs. Since Medicare and Medicaid pay a hospice on a “per-diem” or daily basis for all the services needed, the hospice is receiving payment on the assumption that it will actually provide those services. When a hospice does not provide services needed and which you are entitled to, that hospice may be involved in “health care fraud.” You can help stop the rampant exploitation of the Medicare and Medicaid systems by unscrupulous administrators. report these violations to the Office of the Inspector General. (See “Links to Report Fraud in Hospice” at Section 10 of this text) .
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