At 12:38 PM 2018-12-21, Michaelsen, Linda wrote:
As I am sure you all know, in the US, Medicare patients can choose to be covered under “Hospice” care if their condition is considered terminal. Can you tell us how we would model that in the FHIR Resource(s)?
Fri 12/21/2018 3:36 PM, Knapp, Paul wrote:
Are you wondering how they would indicate their 'choice' (??? - does it involve a new payor?) or would they pre authorize, or obtain, hospice services and in the Claim resource the hospice provider would indicate the terminal condition as a diagnosis code or Condition resource (or a supportingInfo element could be provided)?
At 03:04 PM 2018-12-21, Michaelsen, Linda J wrote:
With Medicare Advantage programs, the patient chooses directly with Medicare to be in Hospice if they have a terminal condition determined by their provider. Once they do that, Medicare sends an indicator on their monthly membership files that tells the administrator/payer of the Medicare Advantage program that the member has Hospice. Based on the description on the Medicare site, it allows the patient palliative care items but not treatment for the terminal condition.
For CQL on FHIR, we need a way to indicate that choice has been made. It feels like it might be in the Coverage Resource as perhaps an Exclusion? But we aren’t sure so asking FM for input.
Fri 12/21/2018 4:38 PM, Knapp, Paul wrote:
Thank you for the clarification. We will review on FM.
Have a great holiday season.
Saturday, December 22, 2018 2:47 PM, McDaniel, Mary Kay wrote:
I’m still trying to understand the use case.
The Payer and Medicare know the patient has signed up/certified they want/ acknowledge they have moved into the Hospice Benefit.
Hospice is 2 90 day periods followed by an unlimited number of 60 day periods.
An individual can move into Hospice and then out of hospice.
So are you just looking at ‘today’ this person has some flag indicator on their member enrollment files that says they are in a Hospice Benefit period?
Do you need the benefit period dates?
Do you care if they are in a 90 day vs. 60 day period?
Do you need the last date of recertification by the Provider? Do you need to know who the provider was who certified/recertified them?
Are you just looking for someplace to put an indicator? (Like they do in the 271 transaction from Medicare??)
Sun 12/23/2018 8:19 AM, Smith, Anne Marie wrote:
WE are just interested that the flag has been set on the Medicare enrollment file, so the health plan is paying claims using that hospice benefit. The monthly enrollment files include the date, so we would know the dates the person using on hospice and the dates they come off hospice. The quality measure exclusion is typically if they are ever on hospice during the measurement period, you can exclude them from the measure.
We don’t care who certified or recertified the hospice. We also don’t care if it is the 90 or 60 day period. The health plan would just need a place to put the dates and an indicator.
Wed 12/26/2018 10:37 AM, Michaelsen, Linda J wrote:
I need a way in a FHIR Resource to represent that the patient has invoked Hospice care (this will be used by CQL to exclude them from the Quality Measure). We need the same thing for LTI/Long Term Care indicator to exclude them from the Measure.
Wed 1/2/2019 7:24 AM, Hamlin, Ben wrote:
At a minimum within the resource, we would need the flag(s) identified and the attached date since that is the key to triggering the exclusion within the Measurement Period. I don’t think we would need provider certification to activate the exclusion (at least not for HEDIS)
Wednesday, December 26, 2018 11:45 AM, McDaniel, Mary Kay wrote:
I’ll put this all together and we’ll have a time boxed discussion on 1/8, it may carry over to the WGM.
Sun 12/23/2018 10:24 AM, Knapp, Paul wrote:
I am confused as well.
Are you looking for a mechanism to inform Medicare that the patient would like to activate the hospice option?
And/or are you looking for a mechanism to inform anyone but Medicare that the hospice option has been set and validated at Medicare?
For my edification, does this alter the treatments provided or just which bucket Medicare is using to account for the treatments billed - and if the later do providers need to let Medicare know which services are ‘hospice related’?
Sun 12/23/2018 2:15 PM, Michaelsen, Linda J wrote:
Exactly the reverse.
-Patient informs Medicare that they are taking the Hospice option
-Medicare (CMS) sends the monthly membership file to the Medicare Advantage payer
-Medicare Advantage payer wants to calculate measures using CQL on FHIR. The CQL needs to know where to look for this indicator in FHIR because members on Hospice to exclude that member from the quality measure denominator.
Secondarily, the payer may want to include this information in any FHIR communications they have with the provider.