that's taking place tomorrow live. Also, I wanted to let you know that our next webinar will take place on September 12th. The topic of that is going to be, there's gonna be a hospice experience panel essentially. So a discussion with some families who a few current certificates and our former executive director, Sally Weir will participate. They're gonna discuss recent experiences they had walking kind of their loved ones through the process of going through a hospice care. And so certainly will be an interesting and worthwhile session, I believe. So please take a moment to consider joining us for that on September 12th. And then the session on December 13th is going to focus on GIP. And so I wanted you to be aware of that as well. That's going to be again, a good session and hopefully you'll be able to join us. And then we're gonna host our last coffee chat for the year on November 10th. Wanted to make you aware of that because we are, as you can probably tell, trying to do our best to create additional community for you all here with the organization and with your fellow certificates. And so what we are going to do is after this session, we're going to send out a survey asking you all to provide any feedback for us on kind of frequency of these sessions, other topics you might find interesting for our webinar series, those kinds of things. So I'd encourage you to please take advantage and let us know what your thoughts are when you get that survey after this session. So with all of that, I would like to now introduce and encourage Mike Nisko, who is a board member for HMDCB and our moderator for today to take over. So thanks all again for being here. And Mike, I think you're muted. So I think we need to have you get off mute there. Yep. Sorry about that. Having technical difficulties. Thanks a lot, Bruce. Thank you so much. Yeah, I wanted to encourage everyone about that Weatherby program. It should be a very good educational opportunity if you have the time to join that. So welcome everyone. It looks like we have about 25 participants here to our coffee chat. And let's see, I haven't got the appropriate theme with the coffee chat background and the coffee chat mug. So welcome. This is obviously an opportunity for us to come together as a group and discuss certain topics. Each of us has many questions about the work that we do and most of us have the answers and these are opportunities to just put together the questions and the answers and clarify things as a group together. So I'd like to start by just reminding people the first time you speak up to the group, it might be a good idea just to say your name and just real briefly where you're from or what you do and then you don't have to do that every time you speak up, but that just helps the rest of us know who's talking. So again, I'm Mike Mutho and I'm on the board of the Hofstra Medical Lecture Certification Board and I'm the Regional Medical Director for VITAS and I teach at the Stanford Fellowship Program here in the San Francisco Bay Area. So moving forward, let's get chatting. So tell me, we have a list of pre-submitted questions which I'm happy to go to, but I would like to start by asking if there's anyone out there who has a question that they are really burning to ask and see if the group can address. I have a random question. Hi, I'm Keishonna everyone, he's my boss. So I recently helped out a small home health that was self-pay and then earlier this year, I heard about a hospice patient that was self-paying. I didn't know that was a thing until those experiences so just curious about that. Thank you, Keishonna. Can you say that again? So you helped someone who was on, you said on hospice that was self-pay? I was helping a home health program with their annual evaluation just as a consult and then so that came up where they were only self-pay, not Medicare certified and then that sparked a memory of me knowing about a hospice patient earlier this year in a small program that was self-pay and I had never known that was a thing. So I was just curious about that. That's interesting. I'm curious to hear what people have to say about that. I'm familiar with similar programs but what's the experience from the group, Alan? So hi, Alan Rosen, long time hospice palliative care provider currently in Nashville and in terms of different payer sources, that's an important distinction. I'm glad you brought up Kai because people may remember in a prior HMDCB coffee chat, we also emphasized that state regulations could be different. So when I practiced in Florida, when I practiced in Illinois, the state definition of hospice was 12 months anticipated life expectancy, not the Medicare, six months and I'm bringing that up because people will qualify if they have saved Medicare benefits, well, then it becomes the Medicare guidelines that default and as a reminder in 1982 and the pilot that came out, the federal government had zero, many states had 12 months and the politicians split the difference and that's part of where the six months came from. It's also important to keep in mind what the payer source may be because if someone does not have insurance, if they're not under Medicaid, if they may, for example, be pediatric and under a parent's commercial program for healthcare, all of those can be different. The last thing that I'll also introduce, I don't know if others have experienced this, but at a hospice in Florida, we partnered with a PACE program and those people that were on PACE, PACE subcontracted with us as well as other payer sources that may want managed care, they contracted because it was much more cost effective and quite honestly, better outcomes coming to say our hospice inpatient unit, if they were terminal, then having the only option be going to the hospital. I'll stop there. Yeah, this is Chris Downey in Minnesota. We've had patients from time to time, self-pay, either their insurance benefit runs out, they have commercial insurance and they only have so much- Right. Or we have patients that just can't afford it, don't meet the criteria for Medicaid yet or don't have Medicare coverage. Usually we pull funds in to try and help them from philanthropy, but I mean, that is sometimes not, and we have a hospice in our city that does not charge for inpatient at all and we'll take care of patients there and that's all done through philanthropy. Well, thanks, Chris. Yep. So there's a kind of a bit to unpack there. I think there's sort of separate issues in a sense. I think what Shana was saying is some hospices just haven't, they're not Medicare certified. They self-pay only as a hospice, right? Excuse me. Could I, if you are a Medicare certified hospice program who is nonprofit as we are, we just take care of everybody using donated and raised community funds to pay for those patients who don't have insurance coverage, but we don't ask about the patient's ability to pay when we admit them. Yeah, so again, so there's also another issue just to remind people, but so some hospices have chosen not to get certified by Medicare for various reasons. Before there was the Medicare hospice benefit, hospice was a charity. And when you get certified by Medicare, you are subject to their conditions of participation, the rules and certain quality standards. So you, I think in general want to look for a Medicare certified hospice because of the certification process, but there are some that choose not to for various reasons. And one may be resources. They can't, they find it, they struggle to meet the Medicare requirements and others are the opposite resources. I know of at least one hospice in a very well-off area who doesn't accept Medicare because they want to do hospice their way. And they have so much money from donations. They don't need it from the community. I do think you need to be careful about not charging Medicare patients for their Medicare benefit and offering it without doing any kind of financial check. I've heard mixed remarks about whether or not that may be applying to Medicare, that if you're offering free services, whether it might be interpreted as an incentive to refer to those patients who do have Medicare. And I'd be curious to know what others think about that. Hey, Michael, I would like to comment about that a little bit because I've worked my entire career in nonprofit sort of legacy hospices. And if you don't do any financial assessment at all, even when you're providing charity care, you cannot cost it against providing free care and write it off as a charitable gift. And so we always do a very minimal cursory sort of financial assessment before providing charity care just so that we can count that as part of the benefit we're giving to the community when we're raising money. If you don't do any assessment at all, then if you're a 5013C organization, you have difficulty in counting that as charity care. And it's been my experience as well is there's a need to do some sort of at least minimal. It's one little sheet of paper and it's real minimal. It's not real intensive. Ask them what their income, ask them what their resources. You don't have to double check or ask for tax returns, but you have to be able to demonstrate that you did some sort of reasonable inquiry before you can provide that charity care. Can I just make just one comment related to, I had like a few patient on commercial insurance and I thought this is a little bit interesting. The patient was with us on hospice and with commercial insurance. You call the insurance, they authorize the admission to hospice and specifically you need to pre-authorization for GIP and how many days you wanna keep them. But the interesting point probably somehow the patient ended up with Medicare after that. And after he was on a benefit period on the commercial benefit period of five, when he flipped to Medicare, he start again certified for the first time, for like when you split to Medicare, you start, they don't care about how many times he was in hospice before. You start counting the period from the beginning. The one they don't have, I think it's, we have like two different hospice agency in the area. Our hospice has foundations and if somehow they don't have no resource of money, they don't have Medicare, they don't have Medicaid, then the cost will come off the foundations. We deliver hospice benefit to anybody ask for it if they are qualified. They do go through financial screening and so on and so forth so they have to be qualified for this conditions. So you have a foundation. Do you, may I ask which hospice you work for? Mercy Health, Lorraine, New Life Hospice Mercy Health. So the foundation is, the Mercy Health System has foundation by itself, but as a hospice by itself, we have hospice foundation for New Life Hospice only. So this is from foundation of the hospice. And so I would like to, I feel I need to point out one thing there. So I've worked, I spent the first half of my career, about 15 years working at not-for-profit community-based hospices. In the last 10 years for larger hospices, for MEDICIS and for VITAS. And in different markets, the propensity to do charity work can vary considerably. In the smaller communities that I worked at before, the not-for-profits almost exclusively most of the charity work in the community when someone didn't have coverage. But for example, in the Bay Area, it's the for-profits that do the majority of the charity work for whatever reason. So I just wanted to throw that out for thoughts that it's not always, you can't always judge the degree of charity or community benefit based on their for-profit status. If people didn't see this, Mike, I just also wanted to share in the chat, there was a couple of folks who mentioned that they have some Amish patients who are self-pay as well. So that seems Jay, it looked like Jay and Carolyn both mentioned that, that they're strictly, I guess, self-pay, is that right? Yes, and then they sort of determine the visit frequency, maybe just a telephone call one week and a visit another week or whatever. But I guess I never thought about this. We have a home health and hospice in our agency and I've just figured if you're self-pay and you're at end of life, but maybe you're living longer than had they been on Medicare, I would have kept them on my service. But if they're self-pay, what difference does it make? Does it? If you think they have a condition, you thought when you admitted them, it'd be six months or less, but it isn't. Does it matter? That's a great question, right? So we know that when you're certified by Medicare, that you're supposed to provide the same quality care to all your patients, the non-Medicare and Medicare patients alike. But what happens if someone's self-pay and wants to be on hospice, but you don't think they have a prognosis of six months? You think it's longer than that? Is that sort of the question you're asking? Is that okay? Right, so this Amish couple who are 90s, one would definitely make a home health, she could be on home health should she want to because she has a fully catheter. So that would be their skilled need and someone could come every month and change the catheter. But she's end stage dementia, bed bound, so on and so forth. And the physician no longer is involved in her care. So I have been involved in the care. And so it would be, and they don't really have the means for tele-visit. So we're kind of stuck. And her husband at the beginning, they were both admitted about a month apart. He had had a stroke, he had improved, but then he occasionally has these downturns where you think death could be imminent, but then he rebounds. So the nice thing is that they're self-pay and I don't have to wring my hands on the prognosis so much. They're definitely, in my opinion, end of life and we're providing palliative care, but they're technically being cared for by my hospice team. And me. Well, we have an issue. So I'm curious to hear from the group. Yeah. So when you have patients who are non-Medicare on your Medicare certified hospice, how can you vary the prognostic requirement or can you vary the visitation requirement? Can you not have a nurse visit every two weeks? How much variability can there be for the non-Medicare patient. I think that's a great point, Michael. And I think it's interesting what you brought up, Carolyn, because I'd also caution everyone on the call that hospices is, there's more mergers, acquisitions and combinations of different settings of care and programs. There's also more scrutiny. Some of it will come down to who your fiscal intermediary is in the state where you live. For those that don't know, the fiscal intermediary is the go-between on CMS, on the behalf of CMS. All your claims go there and they interpret. Some of them, like Palmetto, have very definitive distinctions. And so some can have a flag if you're getting concurrent hospice care and home health, because the expectation, and it was in the 2020 conditions of participation and other final rule updates, remember that it's relevant for hospice on the terminal prognosis. So what some did in the past to say, well, diabetes isn't part of the cancer diagnosis, so they can still get home health for that separate thing. Regulators are taking a much closer look at that. And I think you also bring up another point. It's not just the payer source, but also the goals of care, because part of the Medicare benefit is that someone wants and accepts comfort measures rather than active curative measures. And so there may be desires, pursuits, oncology, cardiology, whatever those other things are that exceed what that hospice has a philosophy or capacity to provide. So there may be a negotiated in-between. Again, definitely get legal advice and guidance from your fiscal intermediary, because it's not everything being the same. Well, I'm just saying with the lady of my couple, she could be on home health because of a skilled need. But again, there's no Medicare involved. This is 100% self-pay. Right. And which program they are being cared for in my particular agency, I guess I just felt that initially they definitely were hospice in terminal. They're 100% goals of care oriented. These are Amish people who only want comfort care. They're not going to any ER. They're not going to go to the hospital for any reason whatsoever. They have made it clear. They just want help. When they need help at end of life, they wanna be able to call. They need to do of course the visit. So that's the quandary. I just don't know what to do with them. Well, you're acting as a- They've been with us more than six months. Yeah, you're acting as a primary care physician. That's what you're doing. You're doing home care. Pretty much. I don't have any problem with that at all, as long as you're not submitting billing to Medicare. So you're just being a boutique physician taking care of that patient and their family needs. And that's perfectly okay. And I don't know about, and you could provide services through the home care and that's how you're, but you wouldn't put those- No, if they went on home care, I would not do that. They would have to find a person who would come to the house, whether that be MD at home or some other practitioner who would be willing to make home visits. So you're not actually seeing the patient in the home? I do see the patient at home when the hospice nurse goes. Okay. I only go like twice a year. It's not a big deal, but I just, I've been conflicted on what to do with this couple. So Carolyn, are they, you got to get right, they're also on home health? No, they're not on home health. No, they have no service right now, except for what you're providing. I'm sorry, I have trouble hearing. I'm sorry, I'll try to speak up. So they don't have any service other than what you're providing? That is true. Okay. I mean, there's some traps that you might be careful about. If they were on home health and you're providing a service to a patient on home health without charge, and then that home health agency is referring other patients to you, then that could be seen as improper, improper inducement for those referrals. And I think, I don't want to, this isn't me telling you what it is or isn't, but it's definitely stuff, issues that you want to run by legal advice and to make sure that if they are on home health, if that's going to flag anything, that you're getting referrals from them and providing this unpaid service to their patients. For those who are not on home health, I think you also need to just run this by a legal department, right? So if they're enrolled in your hospice agency, again, you're required to provide the same quality service, same, similar standards to patients, regardless of their payer source. Medicare says that. And there may be other layers of regulations at your state level that you want to just double check if you're providing- We don't cover DME or medicines or anything like that when you're self-pay. So that's, and that's exactly the kind of concern I have, is that depending on your state, your fiscal intermediary, it may be seen as a two-tiered quality hospice, and they may not look favorably on that, that you're treating people differently based on their ability to pay. For example, what if you were a self-pay in a hospital and you got put on one floor, but all the people with insurance got put on another floor and got a different standard of care if you had payment? It could be viewed as improper. And again, I'm not saying it is or it isn't, but it's definitely something you want to look at a little more closely and consider if your legal advisors say that it might be concerning. You might actually carve this program out into a totally separate community-based program rather than putting it under the umbrella of your hospice. One thing I'll say on that statement, one way I've, when I've had that situation in the past, I've always, where I don't feel like it's a different tiered system is we're still providing the services that I've always felt like we're providing the services that we own. We don't own DME, we don't own medicines. That's something that we have to, that's something that we have to pay for from the hospice for our patients. What I do own is myself and my nurses and the care we provide. So that's why we're still providing the same level of nurse services, aid services, physician services to the patient. We're just not providing the things that we don't own. And so that's at least so far, you can still check with legal, but I'm saying that my justification on where that's not a different tier of service is we are providing everything that I can provide for free, but my medicines aren't free. They are from the pharmacy and have a cost. And the DME is from the DME company and has a cost that we contract with those people, but we don't have direct ownership of that versus what we do own in our agency is myself and the nurses and the aid. So we provide that type of care to them. So that's just a thought, whether you consider it a justification or a good thought. That's what we think. It's like we have some Blue Cross patients and we are per visit. We're not per DM. We don't cover DME and medicines. And some of them, you only have X amount of visits that you can do in a certain time. And there's all sorts of differences amongst the private insurances and they're not like Medicare. Do anyone else have any thoughts? I actually have a question about this. And I'm not sure, Carolyn, if this is the exact same situation, but I work for a Medicare certified hospice. We do have some Amish and other patients who are self-pay, which actually sometimes means that they don't pay, meaning we're providing the care completely. And in fact, that's often the case. And so we provide the same DME, the same nursing and health aid visits, the same medications that we provide to all of our hospice patients. But one of the things that I've struggled with a little bit, I have a patient right now who's been on more than six months. She still completely looks like she's appropriate to remain on hospice, meaning I think she's still likely to die in the next six months. But I find myself wondering, if she were on Medicare and Medicare was paying, would I be taking her off now as opposed to giving her the benefit of the doubt? Do you know what I mean? Like we all get to the point where we're worrying, like I still think that this patient's appropriate, but they haven't died. They haven't died. They haven't died. Do I take this patient off now? And can I make a different decision since it's private pay or I mean, essentially, since we're just providing the care free of charge? And I don't know if anyone has any thoughts on that or if Carolyn, that's kind of the situation you're talking about. Yeah, no, I totally relate to that thinking. So I have two thoughts about the case for number one. If I don't think, first of all, the six month, it's really CMS, I agree with the first, with Alan, it's almost politically drawn, cut off line. So it's not evidence-based, it's not based on the diagnosis and so on. So six month is related to CMS. So in fact, a lot of insurance, private insurance, I personally spoke to a couple of private insurance when we have patient on, they don't care about the six month. So for self-pay, I think it's the same situation as long as you believe the patient is really have limited life expectancy based on the prognosis and it's consistent with the goal of care, which is focused on the symptom management rather than the disease treatment, basically. So as long as I think you document well, they have limited life expectancy based on their comorbidity and they don't want any aggressive treatment and they want to forego disease-directed treatment, focus on symptom management, I think you're okay. The other point, can you deliver different level of care based on private rather than private? I strongly recommend to check with the legal team because it can be problematic. Now, the insurance, like you mentioned the Blue Cross, they already, the patient, when they sign themselves with their insurance, they already have advanced notes about what cover and what cover from them. Now, I'm not sure if you have the same system for private insurance. Again, I do believe that probably you need to make sure it's not gonna cause any legal dilemma. If you provide services for Medicare, Medicaid patient and the same umbrella with the private insurance, you probably better opt to sublet it like two different agency. One is do not accept Medicare and the other one, Medicare, Medicaid, and the other one will accept. And I did have a problem as a recommendation from a legal, from risk management, do not, if the patients, if the patient has Medicare or Medicaid benefit, you have to send them the bill, even if you don't wanna collect it, but do never forego the bill because it can be, you can be cited as inducement or citizen of extra services, basically. So you have to send the bill even if you're not gonna collect it. What bill would there be if they're on Medicare? I think even when there's no co-pay for hospice, you still have to send them the Medicare billing information. Oh, they get the EOB in the mail, don't they? That's when the patients say, you're being reimbursed $5,000 a month. What have I gotten? What have you done for me? What have I gotten? What have you done for me? Exactly. Yeah. Just with you, this is the net saying the bill is more applicable to my palliative care clinic because palliative care clinic, we have like what they call a facility fee, $15, $20 facility for a patient coming to palliative care. And really we don't care to collect this. Then the risk management call us, listen, you have to ask them for this $15 for, because all the other clinic they ask and you cannot be the only one. Do not ask. So you have to ask for it. Now, if you don't want to pursue any action to collect it, this is a different issue, but you cannot treat them. You know what? Just come in to us. We're not going to send you this if this applied to all the other clinic and they're the same umbrella. Great discussion. Anyone have anything else to add? You want to go on to another topic? Well, there's one other thing to follow up on. And I can speak to this because I also am the chief medical officer of a large PACE program too. And our PACE contracts directly with our hospice and palliative care services. And PACE is actually more highly regulated than hospice a whole lot more. So the bigger issue on the hospice side of things when CMS looks or our physical intermediary CGS, when they look at our connections, it's really about the care plans and what's outlined in the care plan. And so the care plans have to mirror one another. They don't have to be word for word, but they have to at least mirror one another. And then the other area of risk is the medical care plan. And the other area of risk is the medications, right? The medication reconciliation. So if you contract with outside entities, whether it be commercial insurance or otherwise, it's really about what you're stating in your care plan that the team is stating that they're going to provide in the way of services that matters. Beth, I think the question you were asking is ethical, is whether I should keep the, do I alter my prediction and keep providing care even though they're not on hospice? And I think you have to keep the same. I'm sorry, the patient is on hospice. The patient was somehow referred, one particular patient that I'm taking care of now, the patient was referred to a hospice by a provider who again now says, oh, I haven't seen her in a year. I don't want to be the one. And the patient looks like she's dying, but at some point I think, I don't think I'm unique in this, right? At some point someone's been on for some number of benefit periods and I start thinking they still look really sick, but they looked really sick a year ago and are they still gonna look sick six months from now? And what I'm trying to sort of figure out in my own unconscious mind is am I sort of saying, well, this patient doesn't have a doctor, they're homebound, they have no resources, we're doing this for free out of the goodness of our hearts and am I sort of unconsciously saying that I'm not gonna take this patient off because I don't have, because Medicare shouldn't come after me because we're not billing them anyways. And again, it's not like I think this patient's doing fine and they just need help. This is a patient I would be struggling with even if she was being, even if we were billing Medicare, it's just, you know, I start wondering like, well, do I even need to worry about it? They're not on Medicare. I think the struggle is the same no matter what, whether they're on or off and you just keep going by your judgment about it is. I mean, it's relevant at the issue. It's, we all struggle with that, with all of our patients and, you know, there is the push to discharge more now than we had in the past, but we still, I had a patient on for three years, the team today, you know, and we could still demonstrate her decline. So those are real outliers and we don't have many of them, but occasionally they do come across. Has anyone ever had, you know, any sort of audit or anything like that where a private pay patient was included in the review, you know, or a patient who, you know, that free care was being provided? Does anyone know if that's something that, I mean, would Medicare even look at that patient? Does anyone know? I think it all depends on who does your reviews. We're CHAP certified and they just randomly pick charts. So, they get people who are Medicare, they get people who are private insurance, they get people who are unfunded, and we have to treat everybody the same, always the same. That's a great point, Ronald, that you also have to look at, there's a whole alphabet soup. So, the fiscal intermediaries, also the Medicare administrative contractors, the recovery audit contractors, those are focused on CMS type things. You can have state agencies or certification entities that look at what else is happening. Many years ago, it used to be that Medicare focused on claims after the fact, whereas commercial insurance typically had prior authorizations. They wanted to inspect and had to certify documentation and everything beforehand. Now, it is blurring and they're both doing some of the other. So, commercial payers are also looking at, well, after we've paid this, what are the trends? What is happening? And you have Medicare and their auditor saying, wait a minute, we need to take a closer look at this. So, again, they've updated the CMS website and the Medicare learning network resources. I was just trying to find my link. I'll put it in the chat, but it's definitely worthwhile to look at those pages if you haven't seen them recently. I think that's a good point, too. It depends on who the auditor is, right? So, Medicare themselves don't do the auditing for the most part. They contract with state agencies. If you're licensed as a hospice through your state and a state agency comes and does your inspection, they may not ask for exclusively Medicare charts. They may take a random sample of all of your charts and see if you're meeting their state requirements to be a licensed hospice institution. Whereas the Medicare audits are usually specifically based on payments, the retrospective Medicare audits. So, they'll ask you for a sample of Medicare patients specifically. All right. Thank you. Sure. Anything else? Any other questions? Speak up if anyone has any other issue. Can I ask one more question? And if this isn't relevant to anyone, let me know. But when the temporary COVID telehealth rules came in, our hospice, we cover a very small number of people telehealth rules came in. Our hospice, we cover a very large geographic area and we have less than two full-time medical directors. So, we started doing some of our…a lot of our patients don't have access to any sort of internet or anything like that. So, it wasn't relevant all around. But we started doing some telehealth face-to-face visits. We did some medically necessary visits, which we did not bill for. That was our billing department's decision. But does anyone know, in terms of using telehealth for, you know, as the COVID exception for face-to- faces exclusively, you know, if a patient comes off hospice, years later, they're referred, they need a face-to-face before coming on, for example. My understanding is that the…I'm sorry, the COVID, the public health emergency is still in effect and that the telehealth waiver is still in effect. But are people still using the telehealth waiver for face-to-faces specifically? And is anyone sort of sensing any pushback on that? Because I was still…I still feel it's appropriate to not have me in the…you know, going to a patient's home just to say, yep, you can come back on hospice. It just seems like a silly risk to everyone, even though maybe COVID isn't as bad, or some people think that anyways. But I was told that I…maybe I shouldn't be doing that anymore. And I'm just wondering if anyone else has any thoughts on that or knowledge on that. Actually, I sent the same question. I'm not sure if it's going to be answered. Is it the same question, Gina, or…? Yeah, I was thinking of that question. It's very similar. I can pull up exactly what you've submitted, though. I did my research, but I need help, actually, because it's the same. I'm doing…currently, we lost one of the providers. So, currently, I am the only hospice provider doing all the face-to-face visit. And I started doing the virtual visit after the public health emergency in effect. So, this is what I read. And please, if anybody has any correction, correct me. But this is what I get from the CMS website and the others. The virtual face-to-face, it's experimented as of…I do believe…October, right? October. …2020. The emergency was…the public health emergency was up. The Congress voted on it in March 9, 2022, to extend it. So…and I do believe President Biden somehow…okay, so they signed it, but it was expired in July, and they extended it for 151 days, which will be up sometime in this December 2022. So, I'm still doing the face-to-face visit, but I am very nervous because when you go to the website, you have 200 different opinions. But I know President Biden did sign it, so it is a law now, the public health emergency being extended for 151 days since it was expired in July. And that will put us at…we still have a couple of months to go, basically. Anybody have correction or… I asked NHPCO regulatory, and I'm forgetting what month, but it's well into 2023 that we can do this. And last time I looked, I saw October, so we're… Yeah, it's well into 2023. And I also think if we're allowed to do it, why not? And also, for someone coming on to hospice again after having been on, and now third benefit period or greater, it allows admission to proceed more quickly than waiting for me to get over. And we also have a very large service area, and I can't be everywhere at once. So, I like this. I hope it stays. And also, just…this is a little bit selfish, I'll admit, but for me to drive 80 minutes one way to a nursing home to see someone who is nonverbal and practically unresponsive for a face-to-face visit for research, I don't think that's a good use of my time. So, I mean, I love being with my nurses, and I'll do visits simply to be with them, but I'm not…there's no value to the patient specifically by my visit in person. So… And a risk of spreading COVID, I would say. Oh, and that's 100%. I've had COVID, and it was no joke, and I don't want it again. That was back in 2020 before all the vaccinations and whatnot, but I sort of have a PTSD experience from it, and if there's not a need for me to be at the bedside, I'm not going. Except in a home situation, I do go. I feel like I have a little more control over risk. So… Do these facilities have their own physicians? Well, they have their own physicians, yeah, but I mean just for face-to-face visits for research. No. So, have you considered contracting with them for hospice visits and face-to-face visits as a visiting physician? No. That won't work in our agency. Why is that? It's just…I feel like…well, I don't want to get into it, but they're not going to go through all the machinations of having a lot of different…nursing home…I'm sorry, my cat keeps walking over me. It just won't work like that. We've looked into even…there's a nurse practitioner who goes to a wide variety of nursing homes, and for whatever reason, I mean, I guess it's beyond my pay grade, but that's…it's just not going to happen. Well, I mean, I bring this up because some hospices or hospice administrators have this fear that somehow that's going to be improper, but there's absolutely nothing wrong with consulting for… It may be a lack of interest from other providers wanting to do that for us, and also our company not feeling that that's priority because, hey, we have Carolyn. I mean, we have standard contracts for these kinds of things that we can send out, sign it, get it back to us. Visiting physicians are really not closely scrutinized as much as physicians who are paid for administrative services, but doctors who are just going to get paid to do clinical visits or consultants around the community who aren't getting paid, and of course, there's no incentive to refer here. They're just…you have a legitimate need, but you could…even if it was questioned, it really is practically no regulatory threat. Operationally, a very simple thing. So, it sounds like a problem internal, and it's pretty common, unfortunately, with many hospices. But really, with the telehealth, it's been wonderful. It's been a really good thing, and it does allow me…if I have a nurse who's going to…we've extended it. The nurse goes to the home. She wants me to look at something. Now we say, hey, let's hop on the video. The patient's permission and everything, and then, you know, I have actually an impromptu visit, which is…and again, we don't charge for that, but it's just really great. I feel like everybody gains from that. I just really love that. So, I do the same thing, but I think if you're doing a clinical face-to-face visit, if you're assessing the patient, making a clinical judgment, changing medicines, you really need to bill for that. Otherwise, you're being unfair to the rest of us, and you're letting Medicare keep your money. If it's really a clinical visit, it needs to be billed. I can say when COVID first started, I pushed really hard for us to bill and went all the way, you know, to get in touch with people from Medicare, and it went all the way up the chain, and our finance person was just so nervous about doing something improper and felt like she was getting mixed messages and was just terrified of that and refused to do it. So, I think, yeah, that's where we ended up. We don't have a lot of them, but I've been paid for the few I've done. Maybe, I don't know, we maybe have three or four a month where I do a real clinical visit that's not a face-to-face, but we've been paid for those. Yeah, I think if there is concern that I would separate these things, right? So, you can't bill Medicare for a face-to-face visit, right? That's an administrative service, but you can bill them for a clinical visit. So, if in the course of performing your face-to-face administrative duty, you see that there are clinical issues that need to be addressed, then you can even write for a separate encounter and a separate note and bill for that entirely separately from a face-to-face visit, and that's just not going to be a problem. That's what I do. I write two notes. I write a face-to-face note. I write a clinical note. Right. The other thing to take a look at, when are those visits taking place and why? So, again, remember what we said earlier, there's heightened scrutiny, and unfortunately, it's not presumed innocent until proven guilty. There have been so many bad apples that if it looks questionable, seems questionable, there are some auditors incentivized. Those recovery audit contractors are basically bounty hunters. They get to keep, on average nationwide, 10% of what they deny. So, if they deny something, you have to then go through the five levels, and it's only the third level that you get to the administrative law judge. Those are stretched out several years. I give that as a context to also caution, if your agency is only sending you out to do those clinical visits the week before someone's benefit period ends or some other things, you're going to have a harder time than if you have policies and you're looking at it from a quality standpoint. We think everyone should be seen. Now, some of this may be aspirational and you don't have the ability to do so. Again, programs are all different sizes, but I would just caution how you're doing and why you're doing it, and make sure you get proper advice for your community, your fiscal intermediary, and the current regulations. Yeah, that's good advice. Remember, it also depends who's the attending physician, right? So, if there is no attending, or if you're the attending, that you document the indication for your visit, that it's clinical, that during your face-to-face visit, you notice this, and then you go forward with your clinical visit. If there is another doctor who's the attending physician, then you should document some collaboration with that doctor requesting you to assist with the symptom management if you're worried about an audit. Different areas and different auditors will hold that role as the medical director, as a consultant, and that if you're going to get involved clinically with another attending physician's patient, there needs to be some explanation there for why you're going to get involved. The attending physician requested your assistance, the family requested you personally, or the hospice physician to come, and to put that in your note. So, consider carefully whether you are the attending or not in how you approach them. I think there was a physician on one of these meetings a couple of months ago who said that they were now being audited just because they were sort of going out, not timed up with a face-to-face. And, you know, they felt that people are coming on hospice, you know, many, many patients have needs, and they were seeing people pretty frequently and were getting, you know, getting scrutinized because of that. Yeah, I wonder if they were the attending or if it was this issue, because if you are going to assume care for a patient, right, if a patient's coming on to hospice and you are now the attending, and you're prescribing a Schedule II substance, you have an obligation to do a direct examination of the patient according to your state laws. That doesn't go away. I know in California, that obligation still exists. Sorry about that. Other thing I'll also add, Beth, is that the situation you described has happened to many when they're doing extra visits on residential patients, so they're at routine level of care in your inpatient facility, because that was being misconstrued as providing extra services or doing other things that one of the benefits to be in that setting, you're generating more revenue. If that physician is employed or gets, you know, whatever separate compensation, that's another concern. Also, if you have your residential patients receiving residential, meaning routine, the same level of care as your GIP patients, that also has raised flags. So, again, it depends on the situation, the type of visit, how it's also coded, why the visit's happening, and documenting. It's not necessarily documenting more, but making sure you document appropriately. 11.59 and we're reaching the top of the hour. So, um, any, any final comments or thoughts? We don't, we have a habit of ending our meetings on time here. So. Thank you everybody for all your input. I really do appreciate it. Sometimes I feel like I'm out on an island and I really look forward to these chats. Thank you. Yeah, I enjoyed it very much. I learned a lot too, from listening to all of you. So, um, there'll be more coffee chats. Gina, where are you on? Can you tell us when the next one is? Yeah. So we will host our next one, November 10th, and we're going to send out a survey later this afternoon, along with the recording from today's coffee chat. And we're just looking to see how often you guys want these to occur in 2023. So if you get a minute, it's a very brief survey, fill that out. And we'll include a link to the November chat as well. So you can register for that. Thanks so much for hosting Mike. Yeah, no, thank you everyone. This was a wonderful talk. Thanks everyone. Bye everyone. Thanks for joining. Thank you.

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