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Role of the Hospice Medical Director
Michael Paletta MD FAAHPMHospice of MichiganMaggie Allesee Center for Quality of Life
Overview
QualificationsOrganizational StandardsClinical StandardsCommunity RelationsEducation and ResearchSupervision & OversightAdministration / ManagementRegulatory responsibilities
Qualifications: Initial
MD or DO degree with license valid in state where hospice operates
Board certification by ABMS primary board, or DO equivalent
Experience in care of terminally ill* Demonstrated ability to work with IDTAble to collaborate with referring and
consulting physicians
Qualifications: Initial
Able to qualify for appropriate liability coverage
Administrative directors should have additional medical management experience, e.g.--
Budget process
Fiscal intermediary relations
Pharmacy issues
Qualifications: Ongoing
Completes orientation processContinues to meet requirements set out
in job descriptionSubmits to annual competency
assessment where applicableEarns at least partial % CME in H&PMAchieves board certification in H&PM
Qualifications: Certification
November 2012 is last sitting for exam toward H&PM certification for alternate pathway candidates
Eligibility for certification will thereafter require fellowship training
Practice standards will elevatePublic reporting requirements will add
visibility to physician credentials
Program requirements
Hospice medical director coverage must meet clinical and administrative needs and be proportional to census
Job description must fully describe and delineate roles and responsibilities
Organizational structure must support medical director’s role
Certification
Medical directors certify prognosis at admission
Section 418.22 of the Medicare hospice benefit stipulates that written certification of prognosis and eligibility be completed by both the attending (referring) physician and the hospice physician
Certification
The medical director is allowed to certify based on information collected by a nurse from the referring doctor
The RN may admit pending approval for straightforward cases; must consult with MD where uncertainty exists
Physicians are held responsible for acquiring clinical data needed to decide
Re-certification
Medical Directors recertify patient prognosis at appropriate intervals
The IDT conference is a forum for discussion, but, the responsibility attaches to the medical director
The medical director must ask for additional data (labs, records) if the prognosis remain unclear, and visit the patient when appropriate
Re-certification
If the medical director cannot in good faith affirm the prognosis to be 6 mos or less, the patient must be discharged
The physician may delegate, but is responsible for, the plan of transition from hospice care back to the primary care doctor
Face to Face Encounters
CMS now requires every recertification after 179 days of hospice care be preceded by a physician visit called the face to face encounter (FTFE)
FTFE is an administrative, not a clinical duty, and therefore falls under the per diem rate of the MHB. Physicians cannot bill separately for FTFEs
Face to Face Encounters
Persons seeking hospice care who had a prior episode of MHB service must also have a FTFE prior to admission.
Physicians who uncover a new medical problem during the course of a FTFE may bill under E&M codes for the portion of the visit that deals with that issue. The FTFE documentation must be separate and distinct from the E&M.
Care Planning
Medical directors manage pain and other symptoms in accordance with palliative standards of practice
They teach principles of palliative medicine to all IDT members when appropriate
They serve as liaison to community physicians for promotion of H&PM
Care Planning
Medical directors participate in the development and review of care plans as part of the IDT process
This requires:
Regular and full attendance at IDT
Availability to RNs during their visits
Willingness to contact referring doctors
Patient Visits
Medical directors visit patients in all applicable locations (home, ECF, hospital) when clinically appropriate and in accordance with a comprehensive plan of care
Daily visits for persons in GIPDocument visits in timely fashion and bill
M-A and M-B as applicable, using appropriate CPT codes
Clinical duties cont’d
Participate in performance improvement activities for their hospice
Manage pharmacy utilization for patients under their control
Participate in after-hours and weekend / holiday on-call duty to ensure 24/7 access to physician oversight
Participate in hospice ethics committee, if applicable
Advocacy
Medical Directors represent the values and mission of the hospice to the community
They educate community doctors on principles and practice of H&PM
Present at medical staff conferences and other medical education forums
Collaborate with ECFs that have hospice team relationships
E & R
Medical directors should enhance the clinical education of the hospice staff
They should join and participate in professional organizations related to H&PM
They participate in external medical and nursing programs in H&PM education
They may help develop and / or actively support research protocols in H&PM
Oversight
Administrative medical directors interview and approve hiring of doctors
Communicate expectations to physician candidates and be ready to answer Qs
Orient all new physicians, detailing their duties and responsibilities
Conduct competency and quality evaluations at least annually
Oversight
Hospice physicians may supervise RNs and advance-practice nurses (eg NPs) in their clinical duties
However, standards of practice are different for each discipline; physicians may not be familiar with nursing training and standards
Physicians cannot certify or testify about nursing standards
Administration
Hospice MDs must have intimate knowledge of the Medicare hospice benefit, and have a feel for CMS policies & procedures
They must understand the policies of their fiscal intermediary (FI), and have a working relationship with their FI medical director
Admin & Mgmt
Administrative medical directors participate in developing yearly business plans for their hospice
They participate in the annual budget process for their program
They help develop and manage a pharmacy utilization plan
Admin & Mgmt
Medical directors help their programs prepare for survey by regulatory and accreditation agencies
They assist in response and negotiations with fiscal intermediaries and other third-party payors
They help establish physician credentialing processes for their hospice
Compliance
AMDs must contribute to program responses to:Administrative law judge reviewsPre-payment probesAdditional development requests (ADR)Targeted medical reviews (TMR)
Compliance
AMDs must assist program leaders confronted with (and share liability and culpability during):Recovery audit contractors (RACs) Zone program integrity contractors (ZPICs)Office of Inspector General (OIG) investigations
Endangered species..
“Doughnut doctors”Volunteer medical directorsUntrained, non-certified hospice MDsUnlicensed hospice MDsPaid medical directors with no dutiesECF / home care physicians
“designated” as hospice MD
Resources
American Academy of Hospice and Palliative Medicine
Center to Advance Palliative CareThe Cochrane LibraryNational Hospice and Palliative Care
OrganizationMichigan Hospice and Palliative Care
Organization