How do I pay for my care?
Covenant Care financial responsibility advisory for hospice patients having private insurance plans or patients without any insurance Dear Patient and Caregivers, Covenant Care is a not-for-profit organization which is required to submit a statement identifying our charges and any co-pay or deductibles for services rendered to patients covered by private insurance. Also, as a condition of our participation in the Medicare program, we are required to evaluate patients who have no insurance coverage for services rendered to them, based on their “ability to pay.” Please note this advisory does not normally apply to Medicare, Medicaid, or most TRICARE beneficiaries.
As our admissions staff has informed you, Covenant Care provides services to all eligible patients, regardless of their ability to pay. We never deny services to patients because they are not able to pay. We do expect, however, that patients without insurance who have some ability to pay will reimburse the organization on a reasonable basis for the services received. We have developed a “sliding scale” method for determining the fair share of payment for patients with little or no insurance coverage. In many cases, the sliding scale determines that a patient is unable to pay any portion. Covenant Care reserves the right to file a claim against a patient’s estate for the charges for unreimbursed care. Periodically you will receive a letter from us providing an accounting of the services rendered and a summary of reimbursements received. This may also identify the unreimbursed amount for which we are seeking payment. We appreciate your understanding of the requirements under which we must operate and trust this will not in any way detract from your positive view of our program of care. If you have any questions, please contact our Patient Billing Office at (850) 433-2155.
Financial information Covenant Care, Inc. (Covenant) is a not-for-profit, 501(c) (3) organization operating under both Federal and State statutes and regulations. We are committed to providing services to all eligible patients regardless of their ability to pay. In order to meet this commitment, we depend heavily upon the charitable support of individuals and organizations making tax-deductible contributions, on participation by our patients to the best of their ability, and on the reimbursement we receive from insurance or other benefit providers. This document is intended to assist in your understanding of our funding sources.
Per diem reimbursement Most of the reimbursement that Covenant receives from insurance payers, including Medicare, Medicaid, and standard TRICARE, comes in the form of a “per diem”, or daily payment, for each patient. Under this per diem plan, Covenant is required to provide a group of “core services” directly related to the patient’s terminal illness. These include: nursing services, medical social services, physician services and counseling services (such as bereavement, dietary, or spiritual). Other services that are available as needed are volunteer services, physical therapy, occupational therapy, speech-language pathology therapy and homemaker services. Most, but not all, of our private insurance contracts also are structured on a per-diem basis. When an insurance company does not contract with us this way, we look at reimbursement on a case-by-case basis. For other conditions not pertaining to the terminal illness, the patient’s other healthcare benefit coverage continues as it would without Covenant’s involvement. For example, a Medicare hospice patient still retains all of his or her normal benefits under Part A unless the care is directly associated with the terminal illness and is identified within the Covenant Plan of Care (a detailed listing of all the problems and interventions being addressed by the hospice team).
Medicare coverage under the hospice benefit is the single largest source of reimbursement for our services. Under the Medicare hospice benefit, medical supplies, durable medical equipment and drugs related to the terminal illness are also supplied by Covenant Care. All services provided must be consistent with the “Plan of Care” developed by the interdisciplinary group caring for the patient, under the direction of the patient’s attending physician and the Covenant Care Medical Director. Covenant does not pay for services that are not included in and authorized by the Plan of Care. If a Covenant patient insists upon a service not authorized under the Plan of Care, our policies addressing non-coverage situations will be applied, and the patient or patient’s representative will be notified in writing. A copy of the Covenant policy addressing non-coverage, as well as information pertaining to the revocation of hospice benefits or discharge from the hospice program is in the introduction to this service guide.
The Medicaid hospice benefit program is essentially identical to the Medicare program benefits. The additional benefit provided under the Medicaid program, depending upon the patient’s financial eligibility, may be the reimbursement for room and board charges within a participating nursing facility. This is also reimbursed on a per diem basis, and must be identified as part of the hospice Plan of Care.
The TRICARE general coverage is basically the same as the Medicare benefit program except that TRICARE case managers may be utilized. Changes continue to occur in this benefit area and your particular status will be determined upon admission. Private insurance and managed care For those patients with private insurance coverage, including those covered by a managed care arrangement, the reimbursement for the services received must be assessed and handled on a case-by-case basis. In some cases, Covenant may have negotiated a flat per diem reimbursement program similar to those discussed above under the government programs. In other cases, the patient’s insurance company may not have agreed to contract with Covenant, and insurance coverage must be determined on an individual basis. In some cases, a hospice benefit may exist, but may be limited by a pre-determined maximum or “Cap” amount or a time limitation. When coverage ceases in such cases, Covenant will continue to care for patients, regardless of their ability to pay.
Hospice patients with no insurance coverage and limited financial resources
Some of our patients have no insurance benefit coverage. Your social worker may assess your eligibility for Medicaid. If it is determined the patient does not qualify, the sliding scale could be completed. If the patient or family are not able to contribute to the cost of care, this does not create a barrier to admission or to the care provided. All patients will receive the same level of comprehensive services regardless of their ability to pay.
This section provides a brief overview of our various hospice benefit funding sources. We recognize that this is a very difficult time for our patients and their loved ones, and we want to do all we can to simplify financial issues. In addition, there are several resources in your county that may be able to provide additional financial support such as: assistance with rent or utilities, medications, clothing, food, legal assistance etc. If you have any remaining questions, please contact your social worker or our Patient Accounts Department at (850) 433-2155. Once Covenant Care admits a patient using the criteria for hospice services eligibility, it may not discharge the patient at its discretion. There are, however, circumstances under which Covenant Care may take such discharge action. These are based upon specific regulatory procedures for patients utilizing their Medicare, Medicaid, or TRICARE benefits. Covenant Care cannot under any circumstance “revoke” a patient’s hospice benefit; only the patient or legal representative can perform that act, since election of the Medicare, Medicaid, or TRICARE Hospice Benefit is the patient’s right. Covenant Care will not request, demand, or pressure a patient to revoke his or her benefit. Covenant Care will fully inform the patient of ramifications of not revoking the benefit when it becomes apparent the patient may be placing him- or herself in a position in which an increased personal, financial, or other burden may be experienced. Covenant Care will discharge the patient based upon written orders from the Attending Physician and assist the patient as much as possible in his or her transition to another mode of care. Covenant Care cannot discharge a patient based upon the request of a Consulting Physician. Discharge must be based upon receipt of an order from the Attending Physician. If at any time there is a conflict between Attending Physician, Consulting Physician, or Patient as to a discharge decision, the assistance of the Covenant Care Medical Director or other staff Hospice Physician should be sought by the responsible Covenant Care Clinical Manager.
SPECIFIC SITUATIONS AND DEFINITIONS:
Revocations: Beneficiaries or their legal representatives may revoke the Medicare, Medicaid, or TRICARE hospice benefit, at any time and for any reason. Normally, the patient’s other benefits (such as Medicare Part A) will be reinstated at the time of the revocation. Hospice may not revoke a patient’s benefit or pressure a beneficiary to do so. Additionally, revocation of the hospice benefit does not automatically constitute a sufficient basis for the patient to be discharged. A beneficiary may not designate an effective date of revocation that is earlier than the actual date the revocation is made and signed. If a patient chooses to revoke his or her hospice benefit, that patient (or legal representative) must sign a statement documenting that revocation.
Non-Compliance and Non-Coverage Notifications
When a patient elects treatment that does not comply with the hospice plan of care, Covenant Care should counsel the beneficiary on his or her option to revoke the hospice benefit, and provide information on any advantages or disadvantages of the decision the patient may make. The following provides examples of non-compliance with the hospice plan of care: The patient seeks curative treatment(s) for the terminal illness; or The patient seeks treatment in a facility that does not have a contract with Covenant Care; or The patient seeks treatment(s) that are not in the Covenant Care Plan of Care or are not preapproved by Covenant Care. If a patient seeks treatment related to the terminal illness, but which is not consistent with the Covenant Plan of Care, or is seeking/receiving care provided in a non-contracted facility or non-contracted entity, Covenant Care will not be responsible for any expenses incurred by such treatment. The Business Services Division will send a copy of this notification letter to the Medicare, Medicaid, or TRICARE intermediary and the patient’s physician. If the patient is covered under one of Covenant Care’s agreements with a third-party payor, that company will be notified utilizing the same procedures. The case manager shall file a copy in the patient’s chart. If the patient refuses to sign an acknowledgment of receipt of the notification, such refusal should be documented on the form and in the patient’s record. If the care is being provided in one of Covenant Care’s contracted facilities, the Business Services Division will immediately notify that facility of the non-coverage situation. Covenant Care will make reasonable attempts to notify non-contracted facilities or entities, but the primary burden of that responsibility lies with the patient. If a patient insists Covenant Care file a claim on his or her behalf for services received under a NonCoverage situation, Covenant Care will do so but will again advise the fiscal intermediary of the non-coverage status of the claim. The patient should expect to receive a formal determination from the appropriate fiscal intermediary.
Covenant Care must ensure that its procedures for discharging patients are not and cannot be interpreted as “dumping.” Covenant Care must clearly document the reason the discharge was necessary. Covenant Care can discharge (not revoke) a patient for the following reasons: The patient is determined to be no longer terminally ill, with a life expectancy of six months or less in Alabama, and one year or less in Florida.
The patient moves out of the Covenant Care geographically defined authorized service area. This includes the circumstance in which a patient leaves the Covenant Care service area and is admitted to a facility, either inside or outside the State of Florida or the State of Alabama, which is outside Covenant’s licensed service areas. In that case, the patient is in fact “residing” outside the Covenant service area, and Covenant should take steps immediately to attempt the transfer of the patient to a hospice in that service area, assuming the patient wants to continue hospice services and desires to be transferred to another hospice. The Business Services Division shall also notify cognizant fiscal intermediaries or insurance plans of the transfer. If a hospice refuses to accept a patient under such circumstances, both the fiscal intermediary and the Florida Agency for Health Care Administration or Alabama Department of Health should be immediately informed. Covenant’s Business, in concert with the Operations Division, is responsible for these notifications as well.
If the safety of the patient or the Covenant staff is compromised, Covenant Care must make every reasonable effort to resolve the problem(s) satisfactorily before it considers discharge an option. All efforts to resolve the problem shall be documented in detail in the patient’s clinical record, and the Business Services Division shall notify the fiscal intermediary and the State of Florida Agency for Health Care Administration or Alabama Department of Health of the circumstances surrounding the impending discharge.
If the patient enters a non-contracted healthcare facility in the Covenant service area, and all options have been pursued (such as: a contract is not obtainable, patient chooses not to transfer to a facility with which Covenant Care has a contract, transfer to a Covenant Inpatient Hospice Center is not available or acceptable, or the patient cannot be transferred to a hospice with which the nursing facility has a contract), Covenant can then discharge the patient. Covenant Care must make the notifications as outlined above.
Transfer of Patients within Covenant Care System
Since Covenant Care is licensed to provide services in both Florida and Alabama, it is not unusual for admitted patients to move to another location within the Covenant Care service areas. In Alabama, each of the Covenant Care offices is separately licensed by the State of Alabama. In Florida, the offices are not separately licensed, but appear instead on the overall license of Covenant Care, which shows Pensacola as the corporate headquarters. Additionally, in Florida, Covenant Care operates in both District 1 and Sub-district 2A & 2B and has offices in each of these areas. A patient’s residence or home is defined as the patient’s current place of residence, including a private residence, facility, hospice residential/ inpatient facility, or other place of permanent or temporary residence.
If a Covenant Care patient relocates or changes his or her residence from a Covenant Care service area/ office in the State of Alabama to a Covenant Care service area in the State of Florida (or vice versa), that patient would need to be transferred in accordance with standard procedures for transfer of hospice patients, just as if the patient were coming from another hospice program. In other words, we would discharge and readmit the patient, and the patient would receive a new patient number.
If a Covenant Care patient relocates or changes his or her residence from the service area of one licensed Covenant Care office in Alabama to another licensed Covenant Care office in Alabama, the same transfer procedures discussed above would apply, and the patient would received a new patient number, except between Baldwin County/Daphne and Mobile. The offices are licensed separately, but are covered by a single provider number; therefore, the procedure for transferring a patient between Mobile and Baldwin would be the same as for Florida, described above.
If a Covenant Care patient relocates or changes his or her residence in the State of Florida from the service area of one Covenant Care office to the service area of another office within the same District or Subdistrict, the patient would be transferred to that new office, but would not be discharged and readmitted, and would retain the same patient number.
If a Covenant Care patient relocates or changes his or her residence in the State of Florida from the service area of one Covenant Care Office, in one District or Sub-district, to the service area of another office, in a different District or Sub-district, the patient would be transferred to that new office, but would not be discharged. However, this transfer between Districts or Sub-districts would be counted as an additional admission in the periodic reports provided to the State of Florida, but the patient would retain the same patient number. This counting procedure is implemented in accordance with AHCA directives.
The Business Services Division must be notified immediately of any discharges and readmissions in order to ascertain in which benefit period, as applicable, the patient may be. All discharges and readmissions will be counted as separate for both State and Federal regulation purposes. In the case of a discharge and readmission, a copy of the patient’s records will be provided to the Corporate Office, while the original record of the patient should be transferred to the new, receiving office. Billings, as appropriate, should occur only once for the day of transfer, and if the patient is being admitted for inpatient care, the billing should be at the inpatient rate.
Hospice staff must fully and completely document the circumstances of all transfer cases.
Patients who are admitted to a Military or Veterans inpatient facility should not be automatically discharged from Covenant Care, as long as the inpatient facility is within the geographic service area of Covenant Care and, the basic admission criteria continue to exist. Covenant Care cannot contract for inpatient services within Military or Veterans Administration inpatient facilities, but can continue to provide hospice services to such patients. The Business Services Division should follow current regulations regarding any billing to federal or state reimbursement sources. Billings to commercial insurance companies on patients who are admitted to a government hospital will be on a case-by-case basis.
Patients being admitted in any service area that have a reasonable potential to be admitted to any hospital in that area which will not contract (participate) with Covenant Care shall be informed of this situation, and such shall be carefully documented in the patient’s medical record. Any admission to a non-contracted hospital will constitute a “non-compliance” situation and should be dealt with in accordance with the procedures outlined in this policy.
At times, patients are admitted to an inpatient facility (and particularly a hospital) for a condition unrelated to the terminal illness. For example, a patient with cancer of the lung may fall while shopping and fracture a hip. If the patient is admitted to a hospital in our service area with which we enjoy a contractual relationship, we will continue to follow the patient in the hospital, billing at the appropriate “routine home care” rate.
Executive Leadership should be advised/consulted on all potential or actual non-compliance situations. All discharges from Covenant Care not related to the death of the patient and all non-compliance cases shall be the subject of a review by the Performance Improvement Team to ensure compliance with rules, regulations, and this policy. A report of the results of such focused reviews will be provided to Executive Leadership.
Medicare appeal Covenant Care will discharge a patient if he or she is no longer considered eligible for the Medicare hospice benefit. Medicare states, “If your hospice program or doctor believes that you’re no longer eligible for hospice care because your condition has improved — and you don’t agree — you have the right to ask for a review of your case. Your hospice provider should give you a notice that explains your right to an expedited (fast) review by an independent reviewer an independent reviewer contracted by Medicare, called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). This notice lists your BFCC-QIO’s contact information and explains your rights. You can also visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your BFCC-QIO.”