For hospice providers, a skilled nursing facility (SNF) can be a reservoir of possible patients and a potential boost to business. Managing those working relationships, though, can often be complicated, messy and filled with challenges.

Hospice legal experts, association officials and executives discussed the secrets to maintaining successful relationships between SNFs and hospices during an Oct. 8 presentation at the National Association for Home Care & Hospice’s annual leadership conference in Dallas.

“There’s not always a spirit of trust between [a SNF and hospice provider],” Cooper Linton, associate vice president of Durham, North Carolina-based Duke HomeCare & Hospice, said during the presentation. “Sometimes there’s actually the questioning of intent.”

The relationship between a SNF and hospice provider is largely dictated by Medicare’s conditions of participation for each. Under those rules, a hospice provider is required to have written agreements and plans of care in place, while also making sure to abide by eligibility and training standards.

Medicare patients receiving hospice services and residing in a SNF are subject to the same Medicare hospice eligibility requirements as those in the broader community.

In general, trust and understanding are two big issues that frequently pop up whenever hospice providers work with SNFs, Linton said.

But regulatory scrutiny is also quickly becoming a major issue, as government watchdog groups, including the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG), have identified SNF-based hospice care as a prime area for fraud, waste and abuse.

“The reality is there’s a lot of money changing hands,” Matt Fisher, a partner at legal firm Poyner Spruill LLP, said during the presentation. “The federal government tends to like to know where that money is going and has become extremely aggressive in many ways.”

During the start of their presentation, Linton, Fisher and other speakers formally polled members of the audience by asking if they had ever encountered challenges when providing hospice services to patients in SNFs.

Of the attendees who responded, 100% said they had experienced issues.

OIG concerned about hospice care in SNFs

In July, OIG issued a scathing report highlighting several egregious instances of fraud, waste and abuse in the hospice industry at large. The report, which synthesized nearly a decade of OIG’s hospice investigation efforts, also honed in on SNF-based hospice care directly.

OIG accused hospices of using residents in nursing homes to inflate their reimbursements and avoid providing the highest level of care by targeting the easiest-to-treat residents.

Part of the problem is that hospice beneficiaries in SNFs have less complex medical needs than patients in other settings, according to OIG. Among recipients of hospice care in SNFs, about 15% had cancer diagnoses in 2013, for example, compared to 38% of those who were given hospice services in their homes.

Care jurisdiction between SNFs and hospices can often fall into a gray area, Fisher said.

To avoid scrutiny, hospice providers should assume responsibility for professional management of residents’ hospice services. Likewise, hospice agencies also need to make sure they consult with SNF representatives in establishing and maintaining a written plan of care — and that the plan of care clearly outlines which services each provider is covering.

Any changes to the plan of care should be discussed with the patient and SNF, Fisher added.

Hospices are responsible for determining the appropriate course of hospice care, though the SNF is responsible for furnishing 24-hour room and board. A hospice provider needs to offer services at the same level and to the same extent as they would in a patient’s home, Fisher said.

Besides quality of care concerns, OIG is also keeping a watchful eye on kickback schemes and transfers between SNFs and hospice care, Fisher said.

If hospice providers and SNFs don’t coordinate care and — whether intentionally or unintentionally — violate Medicare rules, they could potentially incur dire consequences. A Mississippi hospice owner, for instance, currently faces up to 10 years in prison and up to $250,000 in fines after pleading guilty to one count of conspiracy to commit health care fraud.

“These penalties, especially for a smaller organization … these could be penalties that could effectively be a death penalty,” Fisher said.

Good working relationships a must

Trust issues typically crop up due to the natural tension that arises when skilled nursing facilities give up their ability to provide some skilled nursing care, as hospice patients must forgo curative care in favor of palliative care under the hospice benefit.

At that point, the hospice provider takes over the bulk of the Medicare billing, with SNFs being reimbursed by the hospice.

“There’s this tension between the referral source, often the skilled nursing facility, and the hospice provider,” Linton said. “When they make that referral, they’re maybe ending their ability to bill at a substantially higher rate.”

Additionally, cases of hospice providers going into SNFs and poaching staffers aren’t unheard of, Linton said. That’s especially egregious for institutional operators, because SNFs face turnover rates even higher than those in the hospice industry.

To support communication and build relationships, hospice staff members working inside a SNF should “know at least five people” from those facilities, Linton said. Hospice leaders should similarly ask themselves whether they know the leaders at the SNFs where they either currently work or are targeting future business.

“If the answer is ‘no,’ you’re missing a tremendous opportunity to move that partnership from a transactional-type of business relationship to one that is far deeper,” Linton said. “And that may actually improve your business, but that’s not why you should be doing it, in my opinion.”

Reduced hospital readmissions and increased operational performance are among the benefits that arise when hospice providers and SNFs work together seamlessly, according to Tim Rogers, president and CEO of the Association for Home & Hospice Care of North Carolina, who also participated in the presentation.

Along those same lines, patients are more likely to receive accurate pain assessments and treatment with more consistent pain medicine delivery, Rogers said during the presentation.

Written by Robert Holly