Medicare Coverage and Home Nutrition Support– a Complex Issue

Mrs. Smith, a 62-year-old Medicare patient with a long history of Crohn’s disease, is admitted to the hospital with severe abdominal pain and obstruction. Her care team performs her fourth small bowel resection, leaving her with about 5-½ feet of small intestine, and prescribes long-term parenteral nutrition (PN). She is referred to a home infusion provider, which reviews the records and determines that Mrs. Smith may qualify for Medicare coverage of home PN (HPN) under Situations G & H of the Parenteral Nutrition Local Coverage Determination and requests her need be documented in her medical record. Her doctor insists this isn’t necessary since she is clearly malabsorbing, based on the history of her weight and her lab work. After several months on HPN, Mrs. Smith is thriving: her labs are improving, she’s gained some weight and says she is feeling better and has more energy. But when she receives her Medicare Explanation of Benefits she is shocked to learn that Medicare has audited her home infusion claim. Because the PN was not addressed in her medical record, she now owes more than $50,000 for her home nutrition care.

While Mrs. Smith is not a real person, the story is typical of many home infusion patients whose huge bills could have been avoided had proper documentation been provided prior to the start of care. This is why Option Care is diligent about requesting all of the appropriate documentation of orders for HPN and home enteral nutrition (HEN), challenging though that can be for the busy discharge planner who is trying to get the patient out of the hospital and back to the comfort of home as soon as possible. Under the circumstances, it’s tempting to avoid the burdensome paperwork and hope the patient isn’t audited by Medicare. Increasingly, however, that’s a risky proposition. Option Care has observed increased Medicare audit and appeal activity during the past several years. In Fiscal Year 2015, Option Care processed more than 6,000 Medicare appeals for all therapies. In Fiscal Year 2016, that number spiked to nearly 9,500. HPN in particular is extremely costly, and Medicare is being increasingly diligent about ensuring that level of care is warranted. Because an increasing number of Medicare nutrition patients are audited, it is vitally important that their conditions are carefully documented and that other possible avenues for feeding are clearly ruled out. Despite the upfront legwork involved, it’s far easier to gather that documentation prior to the patient’s release from the hospital than weeks or months after they have been receiving the care. The objective evidence necessary to support home nutrition therapy depends on the diagnosis, but may include operative reports, record of detailed intake and outputs, X-rays, blood and other test results, nutritional assessments, studies (e.g. fecal fat studies, swallow studies) and progress notes.

Option Care is committed to ensuring home nutrition support patients aren’t saddled with huge bills when Medicare could be paying. In 2016, Option Care filed Medicare appeals for more than 2,200 nutrition patients, of which more than 81 percent were found favorable and covered by Medicare for nearly $2.5 million. Less than $11,000 in care was found unfavorable and may have been billed to the patient. Option Care knows that the financial aspect of care is extremely important to our patients. Our clinical and reimbursement professionals work together with referral sources to ensure that the care our Medicare patients need is covered to the fullest extent of their insurance policies.

Obtaining the correct documentation prior to the start of care can help with the appeals process if Medicare claims the patient doesn’t qualify for the level of nutrition required due to Medicare’s antiquated malnutrition diagnostic tools. Currently, Medicare’s coverage of nutrition levels doesn’t coincide with the American Society for Parenteral and Enteral Nutrition (ASPEN) guideline recommendations, according to data that were presented by Option Care at the 2016 and 2017 Clinical Nutrition Week (CNW) meetings.

– An Option Care abstract presented at ASPEN CNW 2016 documented that HEN patients who require higher calorie levels may be forced to pay for some or all of their care due to Medicare’s outdated coverage requirements. The study analyzed 62 patients with HEN prescriptions of more than 2,000 calories, which exceeds Medicare HEN coverage and requires adequate documentation. Researchers determined that 81 percent of those patients were prescribed calorie levels in agreement with ASPEN Adult Nutrition Support Core Curriculums and ASPEN 2002 Guidelines.1 In other words, by far the majority were receiving the recommended level of treatment, and yet Medicare would not reimburse without documentation justifying the nutrition prescription.
– An Option Care abstract – winner of the ASPEN CNW 2017 Abstract of Distinction Award – reports that Medicare’s coverage of HPN falls far short of ASPEN guideline recommendations.2

At Option Care currently, 20 percent of HPN patients and 40 percent of EN patients are on Medicare, a percentage that is expected to grow as the population ages.3 Option Care is committed to ongoing data collection and presenting research to further improve patient care and help ensure alignment of access and coverage – for all patients, whether covered by Medicare or private insurance.

1. Jacobson N, Tu N. Medicare’s 2000 calorie level limit for home enteral nutrition – does it correlate with published guidelines? Presented at the American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week; 2016 Jan. 16-19; Austin, Texas.
2. Tu N, Korpolinski R, Jacobson N, Sloan M and Luszcz N. Medicare parenteral nutrition criteria overlooks a segment of home patients that meet current practice standards. To be presented at the American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week; 2017 Feb. 18-21, Orlando, Fla.
3. Option Care data.