Home Parenteral Nutrition Reimbursement

12	Home Parenteral Nutrition Reimbursement
	Marianne Duda, MS, RDN, LDN, CNSC, Deborah Pfister, MS, RDN, CNSC, and Jody Strain

CONTENTS

Medicare

Medicare Coverage Limitations: Coverage Provisions

Medicare Coverage Limitations: Covered Situations

While home parenteral nutrition (HPN) is life saving and life sustaining, it is a medical therapy for which reimbursement is also essential for the patient due to the cost. Third-party insurance coverage for HPN includes commercial or private payers (group and individual plans), federal government payers (Medicare), and state-run programs (Medicaid). Coverage under these payer types can include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), ACOs (Accountable Care Organizations), medical benefit, pharmacy benefit, government exchanges, and the list goes on. A physician’s order is necessary and accompanying documentation is often required to substantiate the need for HPN. The hospital-based team and home nutrition support clinicians are the essential link between the insurer’s medical policy and payment for HPN, related supplies, and services. It is important for the clinicians, home infusion provider, and insurance company to work in partnership with the patient to understand options for coverage.

With the passage of the Patient Protection and Affordable Care Act in 2010, lifetime caps on insurance coverage have been lifted, family coverage has been extended to include children up to 26 years old, and preexisting condition clauses have been eliminated.¹ Despite this standardization, qualification and reimbursement for the provision of HPN continues to vary by payer. Commercial insurers offer varying degrees of coverage for HPN and related supplies that are based on individual policy limitations. Government payers include Medicare and Medicaid, whose original legislation established publicly run insurance for the elderly and the poor based on mid-1960s medical practice and life expectancy. Government and commercial payers often reimburse for a limited number of visits by home health nursing, but as of this writing, few insurers provide payment for other clinical services involved in the management and monitoring of PN consumers in the home setting.

Within the hospital setting, PN therapy is usually initiated at the discretion of the medical team and may be provided for a variety of reasons. All clinicians should have a basic understanding of how HPN is covered by commercial and government payers when managing patients who may require home nutrition support. The home infusion provider with expertise in reimbursement should work with the prescriber in collecting appropriate documentation that supports medical necessity and expected length of need for HPN.

In addition to records obtained from the attending and consulting physicians, the progress notes from dietitians, pharmacists, nurses, wound and ostomy specialists, and other members of the health care team can assist in documenting clinical need. The medical record is not limited to hospital documents, but may include records from physician offices, clinics, nursing facilities, home health agencies, other professionals, etc. A.S.P.E.N’s 2014 Home and Alternate Site Standards also specify that the medical record include documentation supporting the criteria for HPEN as set by the insurance carriers.² Additionally, A.S.P.E.N. standards recommend verification of insurance benefits for HPEN, obtaining insurance authorization prior to the provision of service, an explanation of benefits and cost of service be provided to the patient and caregiver, and a system for payment for out-of-pocket expenses for medically ordered enteral and parenteral formulations, supplies, and services be in place.² Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient on their own to determine that HPN is reasonable and necessary.

MEDICARE

HPN therapy is a covered benefit as long as the patient carries Part B coverage and meets the coverage criteria in the Parenteral Nutrition Medical Policy and Local Coverage Documentation (http://www.medicarenhic.com/viewdoc.aspx?id=1661). Part B coverage was enacted in 1965 with the original Medicare program (Part A) and implemented in 1966. Medicare began providing coverage for HPEN (Home Parenteral and Enteral Nutrition) under the Part B, Prosthetic Device Benefit in 1976.³ The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services, has administrative oversight of Medicare, Medicaid, and other programs.

Enrollment in Part A, which covers hospital care, physician charges, skilled nursing facility care, nursing home care, hospice and home health nursing, is automatic at retirement age or disability and completed through the Social Security Administration. Medicare Part B coverage is optional and may be selected at the required time period when eligible, or at special enrollment. Part B has a monthly premium that can be automatically deducted from the beneficiary’s monthly Social Security payment.

Medicare Part B pays 80% of the allowable charge when criteria are met. The remaining 20% of charges are billed to a secondary or supplemental insurance, Medicaid, or to the patient. In the event that the patient’s medical condition does not meet criteria as set by Medicare Part B, and when a denial of payment is obtained from Medicare, a “true secondary” insurance policy will often provide benefits for HPN. (Once the denial from Medicare is obtained, the secondary insurance becomes the primary payer.) Supplemental insurances will provide payment for the remaining 20% of allowable charges, but only if approved and paid by Medicare Part B. Medicare Advantage plans, also known as Medicare Part C, are managed by commercial insurance companies, also have a monthly premium and generally follow the Part B guidelines for medical necessity of HPN. These plans can also have coinsurance responsibilities.⁴

Information verifying Medicare Part B coverage criteria have been met must be present in the patient’s medical record. It is recommended that home infusion providers proactively obtain and review appropriate medical records and maintain a copy in their files. These records are not routinely submitted to Medicare with the initial claim, but must be available upon request.

Within the infusion industry, providers occasionally utilize data collection forms to ensure they are gathering appropriate documentation to support the Medicare claim. These “provider created” data collection forms are not sufficient by themselves to document medical necessity, even when affixed with the physician’s signature. Any information they contain must be corroborated by documentation in patient’s medical record. The type of records that need to be obtained will depend on underlying medical condition which requires treatment with HPN (Table 12.1).

TABLE 12.1

Medicare Documentation Criteria

Situation A—Massive Small Bowel Resection

The medical records should document:

• Details and date of surgery

Suggested additional documentation:

• Admission health and physical

• Progress notes

• Discharge summary

• Operative report

Situation B—Short Bowel Syndrome

The medical records should document: