Chris, did you get the questions? I'll be fine. Okay. Welcome everyone. Thank you so much for joining us today. We're going to go ahead and get started. My name is Gina Parisi and I currently serve as HMDCB's Executive Director. And before we start our coffee chat today, I just want to share a few HMDCB updates with everyone. So the first one is that we'll have, sorry, my slides are not advancing. There we go. So our next webinar is going to take place on March 18th at 5 p.m. Central and that will focus on hospice core roles and responsibilities. And then we're also partnering with Weatherby Resources again this year to host the Hospice Physician Compliance Conference. They'll be hosting two sessions this year, one in April, one in July. So the April session will take place April 18th and you can use the code on the screen to receive 10% off the registration fee. And then the initial application is currently open. So if you have any non-certified colleagues, you can encourage them to apply by July 31st. And to anyone whose credential does expire this year, make sure to complete the continuing certification program by October 31st. And something else I just want to share with everyone is that I know during today's session, we're going to spend some time talking about lessons learned at this year's annual assembly. So if you didn't get a chance to attend in person, you can still purchase the recordings on AHPM's website. And so just make sure to do that. You can register by May 14th and then you'll have access through June 26th. And the great part about that is you'll get access to the education, but you'll also be able to claim CME. And to anyone who did attend and register for the live annual assembly, you get automatic access to these sessions as well. And then we will go over these questions today. But before we do that, I just want to very quickly introduce our facilitators for today. So Drs. Todd Coté and Robin Turner will be facilitating our coffee chat. Dr. Coté is our current president and Dr. Turner is our current education committee chair. And we'll also be joined by Dr. Chris Jones, who is a volunteer with HMDCB and as we all know, is a billing expert. So he's going to help us answer some billing questions and I'll now hand it over to Dr. Coté to start us off. Yeah, thank you Gina. And again, our intent as moderators, Robin and I, is to listen to you all. By the way, Chris Jones is more than just a billing guru. He's a guru in many areas of expertise. So we're delighted to have him. And to jump kind of right into our discussions, Chris has some limited time with us to start. So we kind of maybe wanted just to jump into some of the billing questions. And I've seen some of the names. You're more than welcome to call out the question that you asked. So I'll leave, I see some of your names there associated with these questions. You don't have to because, but if you feel comfortable, I'll pause there and we can just jump right into some of these, again, billing questions for hospice physicians. Anyone? Hi, hey, this is Jeff. Can you hear me okay? Yes. I submitted the question about billing and I'll just briefly kind of re-ask it. But I'm with Intermountain Health based in Utah. We recently merged with SCL and other companies. And so we've been kind of trying to standardize how we approach a few things. And one of them is around fee-for-service billing and the entity in Colorado approaches it very differently than we do. We historically have been a very Uber compliant company, but since I've been doing hospice there for the past 10 years, we were allowed to bill for an initial H&P visit. Like someone first came on hospice and we would go do an in-person visit and we would bill fee-for-service H&P. This doesn't happen very often, but we were doing it. And then we also did some symptom management fee-for-service billing. But in talking with my kind of leadership colleague in the Colorado area, they stopped doing all fee-for-service billing because their understanding from what she described as recent COP changes in Medicare that, you know, like the family has to ask for a visit, has to be approved with an IDT, any kind of provider visit outside, you know, a face-to-face. So I just wanted to see what others think about that. Does that make sense? The question makes sense. And what they told you is not right. I guess that's as specific as I can be. So you, especially if you're the attending of record, even if you're not, if you're the medical director, you're the person who needs to make sure the patient's okay. So there is no prohibition against visits. In the first 180 days, you don't have any statutorily required visits, but if the patient needs seeing, see the patient. The encouragement that I would give is whatever symptom you see them for, that you would add that as part of your IDT documentation, right? Have that as part of a nursing care plan likely, but you would bill a symptom visit the same way that you would bill a symptom visit for a palliative care patient or for a GI patient. So if they've got dyspnea, you see them for dyspnea, you fiddle with the medications, and then whether you bill it on complexity or on time, you've got the ability to do that. I think you would want to make it clear that you weren't like just driving around, popping in on people against their will, right? So there's somebody, there's something that made you go see that patient, either patient noted symptoms to the nurse or family noted symptoms to the nurse. I would have some documentation about why, technically not required. I wonder if they're kind of hearkening back to the consult code language back in 2010, that was the three Rs, request, render, and report. Those aren't required anymore and haven't been for 15 years, but maybe there's some amount of risk for that $120 visit. I think there's way more reward from the hospice's perspective to show that you're taking good care of the patient. If it's a nurse practitioner, you're obviously not going to be able to bill that unless they're at the attending of record. And there are some nuances that way, but I don't have any reason why you shouldn't take good care of the patient. And if they need a visit, go do it. How about for a new admit that you're just going to see two or three days after they just got admitted? Yeah, I mean, I guess I have kind of two thoughts there. If you're going to be the attending of record, you're essentially being asked to transition that patient's care to you. Boy, the best way to do that is to meet the patient and their family. Can I imagine you go out and see somebody who's actively dying two days after being signed on, they've got Roxanol 5q6, they're fine because they had the head bleed and they don't need anything. Yeah, I'd probably still bill that if I go out there. So I would frame it as, I would put some language in my note of, I am caring for this patient as the hospice medical director, and either did an in-person visit or a telemedicine visit to establish care with the patient and family. I can't imagine anything inappropriate there. Okay. That's kind of what I gathered from trying, you know, I did a super sophisticated Google search on this topic and I kind of came up with, as long as you document, it's really important at least to document the reason for the visit. Like you said, you can't just say, oh, I happen to be doing a face-to-face three blocks away, and so I stopped in to say hello and bill for that. And I'll support the administrator, whoever in Colorado, when you do the visit, what comes out of that visit should show up on your IDT documentation, probably should show up on your nursing care plans. But I don't think it has to be the other direction where until you have an IDT where some nurse goes, oh my God, it's impossible to take care of these people, that they just have to keep suffering. Like, I think you take care of them when you take care of them and you make the paperwork match the work afterward. Todd, Robin, anybody else open for anybody who wants to fight with me about that? Hey, Chris, it's Lainey at Four Seasons. Thanks for joining. You probably know we do a lot of physician billing, like tons of it. And I've just been, I don't know, with the recent landscape, I've just been more worried about it, especially since we do it not necessarily when needs arise, but just kind of regularly, you know, kind of scheduled. And I'm not sure if that's becoming riskier at this point. Nothing that I've heard. I'm open to anybody else who's gotten any concerns. I don't think this is on an OIG work plan. Like, I've not heard any of that. Todd, is this anything that's popped up in Kentucky? No, and it's, you know, we haven't heard this either. You know, the only other problem for physician billing, I'm pretty sure it's under the cap. So there have been, and many over the years, a lot of physician billing, as you're mentioning, Lainey, not suggesting you're doing too much and that it's going to affect your cap, but that is something to think about. But again, particularly how Chris so well articulated, I do think we're not doing enough visits. And I think now, of course, the fear is when we all start doing appropriate medical necessity visits, then Medicare is going to pay attention to the increasing millions of dollars that are being paid out. I mean, there's always been that thing, but, you know, I have not heard of risk. I think if you're doing it appropriately and well, and again, doing good patient care, as Chris so well outlined, I think scripting it to your other physicians and MPs is really, really important because Lainey, as you know, they're going to hear, oh, I'm supposed to do five visits and, you know, that sort of thing. The productivity issues should be well scripted also, as far as approaching particularly medical necessity visits versus the needed administrative visits that we all sometimes frustrate about, but I think can be important also. Okay. That makes sense. Thank you. Other things to think about around the billing side. The question may come up around telehealth. There are technically a new set of codes this year, although they're not used by a ton of insurances. Here's the 10,000 foot is, if you're doing a telemedicine visit, for the last couple of years, you've been able to say, well, I would have seen them in the home, so I'm going to bill a home code. Well, that's not a thing anymore. Now, they don't care how you would have seen them. They only care how you do see them. We've essentially landed for all telemedicine visits. Here's the way I want you to think about it. It's a little bit complicated, but I'm going to try to make it make sense. If you do a video visit and your patient is paid by CMS, which is going to be what, 85 percent or so of hospice patients, you're going to use the new and the follow-up office visit codes. 99202 through 205 for the initial, 212 to 215 for the subsequent. That's for video. Audio is a little bit trickier, audio only. They are still payable. They're not payable with the telephone codes that we've been using for the last couple of years, that 99441, 442, 443, those codes are gone. Here's how I want you to think about audio only CMS. What I just told you was audio video CMS, that's the regular office codes. This is audio only CMS. If you only spend five to 10 minutes on the phone, audio only with the patient, then your code to bill is a new code called 98016. It's called brief audio video check-in, 98016. The idea with 98016 is that it's five to 10 minutes, audio only, a key is that the patient or family has to initiate. I call this the dialing for dollars code. You can't just say, hey, I had a cancellation, I was thinking about you, and talk to them for six minutes and take Medicare's $17. Lookout world, that's the reimbursement for this code is $17. The patient or family has to initiate. So if you're going to bill an audio only 98016, somewhere in your documentation, it absolutely has to say, responding to a call from a MyChart message, daughter reached out about symptoms, nurse reported family would like a phone call, something in there that says they reached out to me, I didn't reach out to them. So again, audio only CMS five to 10 minutes is that 98016. If you hit the 11th minute, now you're back at the office codes. 11 minutes of a medical discussion, that's the way the language reads, 11 or more minutes of a medical discussion, then you use the office codes for the audio only, assuming, and you're going to have to document this in your documentation, that you had the ability to do video, but the patient or family either could not connect or did not consent. So again, the components of being able to unlock the office codes for audio only are 11 minutes or more, you had the capability to do video and the patient or family either could not, did not connect or would not consent. And then if that's what you've done, then you bill 99202 through 215, the normal office codes. So just again, with video, it's just the office codes, no matter how long you spend, you can bill on time or complexity. If it's audio from five to 10 minutes, it's that new 98016 code. If you spend 11 minutes or more in medical decision-making conversations, then it's the office codes, but you've got to document in that case that you had the ability to do video, but the patient did not. Okay, so that's the CMS story. We're going to use the same structure and we're going to put it in CPT. These are for the private insurers that don't follow CMS's rules. They're a bunch of brand new codes and they basically, it's very well set up. I'm, Phil Rogers and I are the subspecialty advisors from Hospice and Palliative Medicine to what's called the RUC. And the CMS said, we need new telehealth codes. You guys have to show us when you're doing telehealth and when you're not. We can't give these flexibilities forever. So there was this like drag down fight at the RUC to build these codes. And it took like a day and a half and there were 37,000 phone calls. And then at the end of it, CMS goes, we don't accept any of your codes except for 98016. So it was just like so sad, but CPT did accept the codes. They exist in the CPT book. So remember CMS is Medicare Medicaid, that's 85, 87% of Hospice. So for the people who are just plain old Blue Cross or a commercial Aetna plan, the new codes run from 98000 through 98015. And the first four, 000, 001, 002, 003, those are new patient video. The next four are established patient video. The next four are new patient audio only. The last four are established patient audio only. So the 98000 through 98015. And then the only thing to know about that is for the audio only, it's the same story as CMS where for the five to 10 minutes, you've got to use 98016. Once you hit the 11th minute, then you've got the eight audio only codes available to you. What I've encouraged our people to do in my clinic, and again, not in Hospice, but in palliative care, we're just billing everyone as if they are Medicare patients. And we're letting our coders figure out, because you've got to figure out payer by payer, which codes they want. This is outside of what physicians and APPs should have to worry about. So we're billing everyone as if they're a Medicare patient. And then if they're a CPT patient, our coding people are just flipping it from the follow-up office visit to the video follow-up code. And we've got direct crosswalks between those. So let me see what questions I generated in the chat. So 98016, Gina, thank you. Five to 10 minutes, audio only, patient or family has to initiate, agree. Christina's question is probably for the rest of the group. So yes, lots of people you bill. If you're out to do a face-to-face and there's symptom management that's needed, Medicare very specifically said when they put the face-to-face requirement in, as part of the way you're gonna offset the cost of having to do this, you can bill for symptom work if you're out there. You just wanna make sure your documentation is really clear. I did this much administrative visit and separately there was a symptom management need. Christy Saunders, yep, two separate notes. That's the best way that I recommend to do it. The symptoms, you bill for the symptom time. I would very strongly encourage you that you could bill either on symptoms or complexity for the symptom work. And a lot of people are gonna be high level complexity in hospice. They've got a severe progression of whatever disease got them on hospice. Some of them are newly DNR. Some of them you may have, if you have a PCA going, then those folks are all gonna be highest level codes. So, and it looks like Jeff agrees with that. 98000 through 98015 are private insurances only. That's the CPT. 98016 is the only one of the 17 new codes that CMS and CPT jointly agree to use. So 98000 through 015 only CPT, 98016 is CPT and CMS. And Jeff's question about telehealth and Congress, a lowercase Congress, which I agree with. They, CMS, HHS have basically said, we do not have the statutory authority to continue telehealth in the way that it's been past March 31st. So we got another five weeks. What we're hearing from the AMA lobbyists and from AHPM's lobbyists is the cat's out of the bag. There is broad bipartisan support to extend telehealth. So the question is whether, I'm gonna say this as non-politically as possible. I don't think we're currently in a Washington situation where some longitudinal well thought out policy will be built in five weeks. So what we're expecting is that they're gonna continue it as it's been for one or two years. We're gonna have to put something together nationally to actually build a proper telehealth. But I don't, what I've been saying is if they go back to requiring in-person visits, we're gonna have to put the mass casualty tents up in the parking lot for our palliative care clinic because I don't have any rooms to see these people in. We do 71% telehealth now. I just, I don't have nurses. I don't have rooms. So I don't think it'll go back to the way it's supposed to or the way that it used to be with the geographic requirements in the originating site. But technically March 31st, that's what's expected. At my place, we are not even building a contingency for that because we just, I have video visits on April the 1st and April the 2nd planned. I'm gonna keep my head in the sand and hope that we get the extension that everyone expects. So there's a little bit of a soliloquy, but hopefully helpful. I'm happy for questions around telehealth if people have it. Yes, thank you so much. I, you know, you're always so valuable. I wish we could just talk to you every day, but. My wife, my wife recommends against that. No, no, no, I understand that. Well, this, it'd be just about the numbers and everything. Here we go. But I don't know if you have to go or if there's any more questions for Chris. There's one in the chat, if I could bring it up. We may have answered it, but there's a question from Rachel, who's asking about doing video visits for symptom management with hospice patients. She is stating, Rachel, you could say this yourself, I'm sure, but she always does those in person. I don't know if there are any comments from you on that. I have to imagine some of it depends on what your catchment area is, right? Like I, this, I wouldn't say from the dais, but I'll say to this small group of 30, like if somebody is on my drive home, I'll do a home visit. So I have 101 year old lady. She's four minutes off the highway. So I pop over there every two months just to see how she's doing. And that's how we do our visits. If the person lived an hour the wrong way, we're gonna do telehealth. So maybe best practice is to go there, but probably a skosh less best practice is to see the patient somehow. So I probably, what do they say? You don't let the good be the enemy of the perfect or perfect be at whatever, whichever way that's supposed to go. I, if you get value out of seeing the patient and you can do it, do it. But if it's something urgent, you can absolutely do telehealth visits through hospice. I didn't know we could build that way for those. That's awesome. Thank you so much. With, if you're gonna do telehealth, it's a 95 modifier. If you connect video, if you don't connect video, it's either 92 or 93. I don't have my 2025 CPT book open, but one of them says audio only telehealth. It's either 92 or 93, and I just can't seem to put it in my brain. But those are the modifiers that you would use along with your typical hospice modifier of GV or GW, depending on how that normally goes. And Chris, there's some language, I believe, that has to go in with a telehealth visit right around privacy and where you are. I think that was made up by Duke's compliance people. Okay, got it. I don't know that there's actually a requirement there. I use two modifiers. I told them to go like stand on the moon so nobody could hear what's being said. I think our compliance people made that up in the throes of COVID. Got it. Okay, got it. And then there's another question. I think the original questioner alluded to this as well. It says our hospice requires a nurse to put a note in the chart stating a patient needs to be seen for dot, dot, dot. And if they don't have that, then the hospice won't pay for the visit. I'm imagining that is for someone who's not hospice affiliated, right? Like if the patient's going to see their endocrinologist to have their A1C checked, that's a way that hospice doesn't have to pay that $400 bill for nonsense. Whatever your hospice does around having the medical director see them is fine. Christy Saunders' question about co-pays. Remember that your patient's billing for symptoms goes through Medicare Part A at 100% reimbursement of Medicare. So there are no co-pays for symptom visits for hospice patients when it's billed through the hospice. So that's actually a really nice thing for the patients. There's no secondary insurance that they have to worry about. Medicare Part A pays 100% of the Medicare allowable without a co-pay. Other things for me, and then I will give you guys your time back. Robin had emailed me earlier and said, there are some billing questions. I was like, let me just come, be faster than typing. So I'm happy if there's anything else that I can answer. And so appreciate you still responding to my texts to you, Chris. Thank you. Yes, thank you, Dr. Jones. You are always so helpful. Appreciate you being here. And I know that Jeff McNally just put a Duke-related question in the chat. Ellie was one of our- Oh, we loved, yeah, we loved Ellie. You just had to point her in a good direction. She had so much energy. Down girl. Alrighty, thanks so much, guys. Thank you. Take care, bye. She's great though, Jeff. Thank you. That's great. You know, I'd like to give Robin an opportunity to talk about if everyone's okay. And maybe everyone on the line, if you could chat. Yes, if you did go to the Academy meeting, we'd love to hear if you were attending. But I'd like Robin to just give her thoughts on, she was very involved in many different ways. And I'd love to hear all of your thoughts if you were attending the Academy meeting. But Robin, why don't you give us some thoughts and experiences. Was that two weeks ago now in Denver? Yeah, yeah, it was two weeks ago. Yeah, before I do that, hey, Carlos, how are you? So good to see you. Good to see you too, Robin. Oh my goodness. I failed to come by the session that you did, the hospice homework. That was in the room. Oh, you were there? I was there, so I'm sorry, couldn't catch up. Yeah, we're catching up some other time, but good to see you, I'm glad you're here. So for some reason, I can't see the slides and you all. So I'm gonna, do you have the list that I sent you? Did you put it on a slide? Let me pull that up, Robin. It's okay, that's okay, I'll pull it up. I just thought I would, I thought you might've had it on a slide. Yes, I just put together for Gina and Todd kind of a list of issues that came up throughout the week. And as we were contemplating these issues, we recognized that any one of these could be an hour or two hour discussion. And we'd love to hear from any of you all as well about your takeaways from the Academy meeting last week in Denver or two weeks ago now, I guess. But if you're okay with it, I'll share some of the issues that came up. And if there were takeaways, share those. Does that sound okay? I'm assuming, I'm assuming I hear some yeses there. So in the homeroom on Friday, it was very robust discussion around many issues. One of them was staffing thresholds and coverage. And that came up because, and many of you may have had the same experience at some point in your hospice career, but a relatively new hospice medical director was being asked to go from 0.8 to full-time medical director and she would lose her current coverage, call coverage by doing that. But that would be taken away and they'd have to reestablish another call situation. And the other issue was that there were 80, it was an average daily census of 80 patients. And there was no plan to add further staff to support her, no nurse practitioner, no other hospice medical director. I don't know if any of you, Alan was there for that conversation. And certainly staffing thresholds has always been a difficult conversation to have with hospice leadership, documenting and supporting the need for more help with patient care. I don't know if anyone has any comments or thoughts on that or. I would. Hi, this is Alan Rosen. I would just add for what I said during that time and as someone who's worked with hospices going now on 25 years, multiple states, that when it came up about staffing, it all depends. The organization you work with, what your patient population, the geography involved. If you're admitting people with a median length of stay that's really low, that means you're turning over a lot of patients. Well, are you organized where your primary hospice team does your admissions and your discharges? That's going to be a more time intensive process as well as what is the overall size of your organization? Those with a lower ADC may have more flexibility to absorb in terms of staffing. The difference becomes if you have a structure where you're seeing team nurses do admissions, do the death visits, cover weekends, as you get larger and let's say you go from being ADC at 300, now you're at 500, now you're at 700. Well, by definition, you're going to be larger and have more deaths and simultaneous admissions. You need more staff to cover that, especially when you have the higher reimbursements on admission and higher reimbursements and expectations for quality outcomes at admission and at death. Therefore, that dynamic may impact your particular census and staffing. Lastly, if they're facility-based, you may have enough patients on census in that facility that you have team staff members there and they're not driving everywhere. So again, that all depends. And I gave an example when I was in Cattanooga, we had mountains. So how you navigate and what distance for staff to get to can also change those parameters. I'll stop there. Yeah, thanks. Thanks, Alan. And staffing thresholds and formulas to support staffing, it's like, what's the flavor of the year? I think back in the day when I first started in hospice, it seemed to be agreed upon that 70 was a pretty good threshold, but that has changed and I've seen upwards of 120 per provider, which seems a bit much to me. But if there are no more comments on that or other thoughts, I'll stop there. Go ahead. Dr. Hernandez had just asked that, like what is considered a full-time patient load? And she did allude to 90. She's read 90 to 120. Yeah, yeah. I don't know, Todd, do you have any? Yeah. I'll just comment as editor of the last two hospice medical director manuals. We tried to, there was early benchmarking in the early 2000s, and that's where you get these numbers 90 to 120 and that sort of thing. And I think that was just a thoughtful attempt at looking at staffing models and then applying it to this. But Alan and Robin, your comments are well taken that if you've seen one hospice, you've seen one hospice and it certainly reflects in staffing models. You really have to, and your leadership should be sitting down with you to understand these ideas and thoughts because I think it's important to how do you staff nurses? If you're in a mountain area, rural mountain area which we're in, is very different than our suburban, Central Kentucky area that we're in versus the Northern Kentucky area. So you have to look at, are there cancers? I mean, it goes on and on. There's a list of at least 25 different things. The Hospice Medical Director Manual, which I'm not plugging but I've always appreciated it, does kind of explore and list out those things. I do think we probably need more research and focus in that going forth. That's a nice HMDCB project maybe, but to look at how, not really a formula to it, but look at, you have to check all the boxes as to what you're doing. And Robin's pointing out something I've always noticed. I used to do 20% administration and 80% patient visit and stuff and IDT. Now it's flip-flopped, which requires time and efforts in different kinds of ways. So I don't want to make it all wishy-washy, but I do think a thoughtful approach to your region, geographically, healthcare, environment, and all needs to be calculated into whatever kinds of staff. I do think there probably will work on maybe standards for this kind of main question of, if you're particularly a hospice physician in a new hospice, what should I expect of a census? My responsibility, that sort of thing. I think these are really important questions. Thanks. Yeah, and I think also maybe how many people you serve as attending of record, you're doing the primary care on them and that plays a role in it too. It's a tough question to answer, I think. So a second issue that came up that really was a little bit of a surprise to me, because I didn't think about this, is what to do if ICE comes to your hospice, your hospital? How do you train nurses? What are your hospices doing in terms of developing policies with how to manage this? And how does it affect care of patients? That was kind of a pretty robust discussion. I don't know if any of you all have worked with your hospices for policies or run into situations like ICE knocking at your door. I'll leave that. Is that something? Hi, Robin. Just talking about this today at our exec operations team meeting and our VP of HR is kind of laid out for us that if anyone from ICE comes that we would put them in a room and ask them to wait and call our VAP of HR, our director of HR. This was on guidance from a lawyer that she had spoken with about this. And then our exec ops team is kind of the backup in case one of them isn't aware. And she's gonna give kind of targeted guidance to like our volunteers and receptionists at our hospice houses who are frontline and maybe our director levels about this. Not just kind of give directed guidance to people who are in places where this might happen. So we're thinking most about our offices and our two hospice houses but we found that helpful guidance. And she kind of just underscored and the lawyer underscored to her that you don't have to respond. You don't have to do what they're asking right away. You can just come in a room and ask them to wait, call her and then they will come and talk to them and kind of what the lawyer's guidance was, just to be polite. But there's time to not do exact, for us to call a lawyer if we want to or not do exactly what they're asking us to do right when they're asking us to do it if that's helpful. Yeah, I think panic mode is probably what sets in. And as usual, taking a breath and a step back and getting people involved to probably know more about it than certainly I do is best. Anyone else with any particular experience? Hi, this is Chris Downey. And I'm with a large, I'm with a large, I have a small little hospice and I have a large hospice and multi-specialty, multi-major organization. And they have developed policies that basically say that if ICE comes to the door, we have to provide HIPAA regulation, we can't reveal any information whatsoever and then to give security a call. So that's how they're handling that part. The policies really revolve around HIPAA and disclosure that we don't have to give any information about our patients to anybody else. And I don't understand if there's a warrant or something else available there, that's probably where security comes in. One of the comments that was made in our discussion was, I guess, I in some ways would never know if they were documented or undocumented, I guess. So certainly we have to treat all our patients the same. We know if they're eligible for Medicare or have insurance, but beyond that, I don't know that I've ever asked for anyone's birth certificate upon admission to hospice. So it's a challenge and it may become more of an issue moving forward. Any other comments or thoughts on that? I see something in the chat. Counsel of our affiliate medical center is that they are possessing, oh, if they have a warrant, yes, then probably need to call security and act differently, it sounds like. Again, an hour conversation, I'm sure. One of the hottest topics, if you will, was GIP in the hospitals. And I don't think that's anything new. People are a bit all over the map around that. I think those of us who are purists in terms of the hospice, the experience of GIP in the hospital, we don't always feel like is equal to that in a hospice-focused home or house or freestanding facility. And then there's the other side of the coin where some places that's the only option for GIP provision. And while it may be a scatterbed approach, it's better than not being able to do that at all. Or perhaps it's better than providing GIP in a nursing home where you don't have access to all of the really good medications that you might in a hospital. I think that one interesting comment within the hospice homeroom about the GIP issue was it sounded like there are some hospices who still are even unfamiliar with this and have not established any GIP programs at all and actually thought it was unethical. There were several conferences around GIP provision in the hospitals, the ethics, the challenges, audits, how to deal with audits. So if you do have access to the Academy recordings, some of those have slides or video presentations and are probably worth checking out. I think one of the best presentations or at least the most comprehensive presentations I went to was called basically something like, did we freak out with our first, did you go to that one, Carlos? I'm seeing you nod your head. So that was very well done and helps just outline some processes your organization can take to be sure that you are doing things correctly. And Robin and probably the rest of the group, from my perspective, something that resonated out of that presentation was that although traditionally we had done GIP in the hospital, in addition to in the IPUs, in the freestanding hospice homes, having a contract with the hospital for both routine and GIP is something I kept hearing more and more. Yes. For obvious reasons, obviously, as we do know, just based on the experience in the IPU, GIP criteria can be met a few days, then they are routine, they may come back to GIP. And in the hospital, care for hospitalists and others who do not understand hospice regulations and documentation to support care and GIP, that's very important that we hospices make the call about the level of care while the patient remains in the hospital. Now, I know there is some regulatory lags if it's a routine, what happens, room and board and things like that, but I don't know how the rest of the medical directors in the room approach that situation. Yeah, I'll share our experience, Carlos. And I did give an NHPCO GIP in the hospital in 2008 at the national clinical meeting. So, but that said, we've had, I'm really proud of what we've done here in Kentucky. I learned a long time ago that it's the hospice's approach to the hospital, leadership to leadership. So what we've been able to maneuver, I know it's easier said than done, but is C-suite level, that's when you start to discussions with both the hospice, whether you're a small hospice or large, and the hospital, because you need the CEO and the CFO, they don't understand hospice finance even, so you really have to work together. And then it's a downward trickle. We were starting a new program pretty soon. It takes at least three months of meetings. So my point is it's a commitment also for hospices that can find the time to meet, again, typically C-suite, but the meetings we're in is like dietary and maintenance people, the directors of all the different departments of the hospital meeting with the hospice leadership before you start seeing patients, clarifying all the nuances of regulation, because hospitals have regulation that sometimes clash with hospice regulation. Well, it does, it just, the models don't work together very different. So my point, I would love just hospices to go and sign a contract and start the thing, but again, it falters. I guarantee I've done it for many years. Actually, we've been traveling kind of helping hospices and hospitals start appropriate, well-integrated end-of-life care services. And it's typically the hospital that's coming to us saying, we don't do end-of-life care very well. So these are patients that not only are coming from hospice to the ED and then are admitted, but also people that, as we all know, will probably die in the hospital and need really good end-of-life care. So, you know, and again, who else to go to, but the hospices. I respect the small hospices that it's very hard to send people over and all that. Large hospices like us can probably even collaboratively staff, meaning they subsidize the program with us. CMS made it very clear that you can negotiate a contract. Carlos, what are you kind of talking about? That should be negotiated between the hospice leadership and the hospital leadership with all clarity. You always have bumps in the road, but I'm convinced that you have to address the sophistication of acute care hospitals with them understanding that there is sophisticated hospice care too. That's just my opinion, but it's been very successful for us for many years. We have integrated teams that only work in the hospital. They're actually become kind of extra teams of the hospital, even though we employ them, right? And they're the hospice team, you know, so on and so forth. So it can be done. It's a lot of work. It's the hard road, not the easy road to just kind of get a contract, sign it and start waiting for the call to come in and send your nurse in, so on and so forth. But yeah, Alan, I think Alan had a question, sorry. I just wanted to add for those that are new to this, the hospitals often try in the contracts to get all of your per diem. Do not agree to that. Number one, because they will also send you unfunded patients. Number two, as an organization, you still have your staffing operations, other things. So it should be a percentage accounting for what your staffing and overhead is. If you give them automatically the full amount, it has been questioned in some surveys, are you trying to pay them for referrals? So for those that are new to this, there is something else involved. And by all means, reach out to people within HMDCB, reach out for some guidance because even your local legal support may not be aware of those nuances. Thank you. Thank you. There is a question in the chat from Jeff and just kind of wondering how many of you all may have contracts for routine care with the hospitals, if you also have a GIP program, I'm assuming. Robin, I'll comment. And thank you, Alan, for that comment. The negotiation is about the simplicity of the money. We know that a per diem GIP is about a thousand bucks, right, 999 maybe. I mean, so when the CFO hears us talk simplicity, they, oh, okay, I get it. That reflects into always talk about routine care, what happens if a patient gets stuck in the hospital, which happens all the time anyway, whether they're hospice or not. And they don't have really symptom, high acute symptom need controls. You need to be able to work with your hospital. That's been on AHPM Connect a lot about what do you do about routine. And, you know, again, it starts, I am convinced it has to start with the relationship of understanding between the hospice and the hospital. Now the hospital, Alan, on the other side of the coin has to consume cost of lots of things that we don't have to, because it's GIP and within the realm, you know, that we don't, the hospice won't necessarily have to pay for. So, I mean, there's lots of negotiation. It's more detailed and I'm sorry, we're taking up, I'm taking up all the time, but I'm really proud of our programs. I think we're doing it right. It does unfortunately require a lot of time. And again, this communication, but money's where they usually start. So defining the payment model is pretty straightforward. The technical issues of IT and bed management is where, and we can spend more time on that in a future talk, but yeah, it's a great topic. I do think there's a need for hospices to help hospitals now for dying patients. 20 what, 20% of Americans die in hospitals and that includes the ICU. We're doing ICU hospice care now. So anyway. No, thanks for that. And yeah, it, Jeff has commented a couple of times and so they negotiated down a GIP rate from 70 to 40% of the per diem. So good job. And it sounds like Jeff, do you have a contract for a routine level of care with your hospital then? We don't right now, but we're starting to consider doing that. And I think there'll be open to it, but I know it's done, but we, yeah. Yeah. So obviously this might still be a good topic for this group at some point in the future. And certainly Todd, that would be wonderful if you could come back and share some of your successes. And I think the other thing is, is that, I am a purist of hospice and I was really not all about GIP in the past, honestly. I mean, if I were to take a lie detector test, but the reality is, is that it does improve care for other patients within the hospital as well. And to not share our knowledge and expertise, I think with the hospital, because we want to be the IPU of, you know, the county or something like that. You know, I think I needed to shift my focus and it really has improved care. It's increased awareness around end of life care. And I think it can be a win-win and it has decreased the mortality rate, which is of course the initial impetus, at least from the hospital standpoint. Yeah, so there's lots of conversations here about, yes, GIP downgrade, et cetera. So I think Gina, we might want to put this on for a future discussion here. We don't have too much time, but I'll just share this last hot topic, which is AI and video teaching of your patients. There are a couple of other things, but I think for this group and, you know, the takeaways from the conference, AI is coming and people are using AI characters within video teachings for patients and families, for symptom management, what to expect, how to, you know, manage a medication, et cetera. And again, if you have access to the video recordings, there was a couple of conferences that did actually include a video with AI. It was a little weird for me to see the AI character, but it, you know, it is a technique for teaching in the future. Todd, anyone else have any comments or thoughts? I hope bringing these up has been useful. Looks like there's some good things in the chat, Gina, that you may want to share with people. Yes, definitely. We'll include a resource guide with the recording. Yeah. And if you have any other resources or additional questions, please feel free to email them to me. I put my email in the chat and I'll put it in there again as well. And I know we're at time, Robin, so I just want to thank you and Todd for facilitating today's chat. And thank you everyone for attending. We'll hold another coffee chat and I think our next one will be in May. So we'll send out emails for when that will be occurring and I'll put my email in the chat if you have any questions in between then. So thanks everyone. Have a good day. Thank you. Thanks everyone. Thank you. Yeah. All right. Have a great day.

Hospice Medical Director Certification Board

hospice care

physician compliance

billing practices

telehealth codes

staffing thresholds

General Inpatient Care

end-of-life care

AI in patient education