The Advanced beneficiary notice (abn) revisited
The Centers for Medicare and Medicaid require a provider to notify Medicare beneficiaries when a service may not be covered under the Medicare program. The Advance Beneficiary Notice of Non-Coverage must be completed by the provider, or their representative, and signed by the patient before a service is rendered.
The ABN advises the patient that the service they are about to receive may not be covered by Medicare. The form must include a description of the service, along with the estimated out-of-pocket cost and the reason why Medicare may potentially deny the service. The services itemized on the form must be clearly explained to the patient (or their representative). Thus, the ABN allows the patient to make an informed decision regarding whether or not to receive the service.
Mandatory use of the ABN is very limited for hospices. Hospice providers are responsible for providing the ABN when required as listed below for items and services billable to hospice. Hospices are not responsible for issuing an ABN when a hospice patient seeks care outside of the hospice’s jurisdiction.
The three situations that would require issuance of the ABN by a hospice are:
- Ineligibility because the beneficiary is not determined to be “terminally ill” as defined in §1879(g)(2) of the Act;
- Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in either §1862(a)(1)(A) or §1862(a)(1)(C); or,
- The level of hospice care is determined to be not reasonable or medically necessary as defined in §1862(a)(1)(A) or §1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions.
NHPCO Regulatory and Compliance Center
Nalmefene HCL injection for opioid overdose treatment
The Food and Drug Administration (FDA) approved Purdue Pharma’s Nalmefene Hydrochloride Injection for the complete or partial reversal of opioid drug effects, including respiratory depression, induced by either natural or synthetic opioids, and in the management of known or suspected opioid overdose. The drug was previously marketed under the brand name Revex (Baxter) but was discontinued in 2008. The product is expected to be available by mid-2022. In a press release, Purdue stated that it will be distributing the drug for no profit.
Pharmacodynamic studies have shown that nalmefene has a longer duration of action than naloxone. Nalmefene HCl can be administered via the intravenous, intramuscular, or subcutaneous route. Nalmefene Hydrochloride Injection is supplied as a single-dose vial containing 2mg/2mL (1mg/mL) of nalmefene base in a carton of 10 vials.
drug cost vs unique formulations
It’s the time of year when most hospices review, update and edit their formularies. The Wise Hospice Options clinicians having reviewed many formularies have found unique formulations that we want to call to your attention. Below is a list of drugs that have formulations that, per unit, cost significantly more than the other formulations of that medication. Based on our review, you might consider making notations on your formulary to call attention to these unique formulations.
Transdermal Fentanyl:
- 37.5mcg = $63/patch
- 62.5mcg = $96/patch
- 87.5mcg = $138/patch
- Standard doses (12mcg-100mcg) range from $15 to $48/patch.
Oxycodone Liquid Concentrate:
20mg/ml = $11/ml
compared to
Morphine Concentrate 20mg/ml = $1/ml
Mirtazapine:
7.5mg tablet/$2 each
compared to
15mg tablet scored at a cost of $1.25 each.
Prochlorperazine Suppositories:
$12/each
compared to
Tablets $0.80/each.
Promethazine Suppositories:
$11/each
compared to
Tablets $0.60/each
Metronidazole:
Metrogel 60mg 1% tube = $240
compared to
Tablets $1.20/each
KCL Liquid:
- 20meq/15ml = $4/dose
- 40meq/15ml = $15/dose
- Tabs & Caps = $0.70/each (Kdur dissolves in water)
Zantac/Ranitidine:
Has been removed from the market. We suggest adding Zantac 360 at $0.30/tablet.
Temazepam:
Does not appear that tablets are available. The 7.5mg cap is $8.25/each. The 15mg capsule is $0.50/each.
If you have questions about these formulations or others please contact Tino Vilches at tvilches@wiseop.com.
cholinesterase inhibitor (chel) and memantine
The approach to deprescribing chEl and memantine
Patients and caregivers may be more likely to engage if they understand the rationale for deprescribing and the deprescribing process. Discuss treatment goals – what do they value the most (cognition, quality of life, remaining independent)? Ask about experience with dementia symptoms when treatment started and over the last 6 months. Ask about side effects.
It is important to take the time to help the individual and family/caregivers understand the deprescribing process in order to make an informed decision.
- Deprescribing is a trial — medication can be restarted if appropriate.
- There are uncertain benefits and harms to both continuing and discontinuing the medication.
- Tailor discussion about benefits and harms to the individual.
- Explore fears and concerns about deprescribing.
- Consider medication costs.
If the recommendation to deprescribe is being made due to progression of dementia, remind family/caregivers that the person with dementia may continue to decline after deprescribing, and explain why.
If the patient has been on any of these medications for >12 months do they fulfill one of the following:
- Cognition +/- function significantly worsened over the past 6 months (or less, as per individual).
- No benefit (i.e., no improvement, stabilization, or decreased rate of decline) was seen during treatment.
- Severe/end-stage dementia (dependence in most activities of daily living, inability to respond to their environment +/- limited life expectancy).
Recommend Trial Deprescribing.
Taper and then stop. If possible, halve dose (or step down through available dose forms) every 4 weeks to the lowest available dose, followed by discontinuation. Plan this in collaboration with the individual/caregiver and relevant healthcare professionals.
Closely monitor for change in cognition, function, neuropsychiatric symptoms. Consider other causes, for example, delirium.
drug shortage list
These shortages are due either to manufacturing delays or shortage of raw ingredients. This is not an inclusive list, but the listed drugs may be used for hospice patients, especially in the inpatient setting.
For a complete list of drugs on shortage follow this link:
To close click the X in the top right hand corner.
About the author
David Bougher
Senior VP of Regulatory Affairs
David is a seasoned veteran of the hospice world and an essential member of the Wise Hospice Options clinical team.
Education:
RN, BSN
Experience:
- Former hospice COO
- 20 Years of education & training experience
- 10 Years of experience at Wise Hospice Options
Connect
- (800) 856-9757 Ext: 203
- dbougher@wiseop.com
Follow
clinical leadership
Tino Vilches
senior vice president of clinical services
Deanna Rice
vice president of clinical services
Available
Wise Hospice Options Services
Please reach out to your account manager for assistance with maximizing your available services, or for potential upgrades to your current system.
EHR Interface Integrations
Demographic & medication interfaces with over 11 EHR's.
E-Prescribing
Web-based prescribing platform for Schedule II's.
24/7 Support
On-demand clinical or technical assistance fast.
EHR Medication Profiling
Med reviews done inside your EHR system.
Advanced Reporting
Drill down into your pharmacy utilization trends.
Clinical Education
Hospice oreiented courses designed for your hospice staff.
Pharmacy Network Access
Unrestricted access to every pharmacy within our network.
Web-based Refills
Send and identify available refills for your patient population.
