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Navigating new hospice billing requirements under the Value-Based Insurance Design (VBID) model

Navigating new hospice billing requirements under the Value-Based Insurance Design (VBID) model

Under the Hospice Benefit Component of the Value-Based Insurance Design (VBID) model, participating Medicare Advantage Organizations (MAOs) are responsible for coverage and payment for all Original Medicare services including hospice care. This brings payment under one source, no longer split between Medicare Fee-For-Service (FFS) and the MAO.

For hospice providers, this model brings a need for staff education and process adjustment. The following is a summary of what you and your team need to know.

Understanding the Value-Based Insurance Design model

As of January 1, 2021, participating MAOs have the option to include the Medicare hospice benefit in their benefits package through the voluntary VBID model. In calendar year 2022, the Hospice Benefit Component has expanded to 13 MAOs in 21 states and Puerto Rico.

Even if your hospice doesn’t contract with the MAO, you must submit duplicate notices and claims to both the participating MAO and Medicare FFS Medicare Administrative Contractor (MAC). The MAO will process payment and pay the non-contract hospice at least the equivalent to Original Medicare FFS payment rates for covered hospice care. The MAC will process the claims for informational, operational, and CMS monitoring purposes.

Managing VBID eligibility verification and dual submissions

To confirm if a patient is enrolled in a participating Medicare Advantage plan, hospice providers need to first verify their Medicare eligibility. This can easily be done in the Inovalon ONE Provider Platform (formerly myABILITY); both Eligibility Workflow (formerly ABILITY COMPLETE) and Claims Management Pro (formerly ABILITY EASE® All-Payer) support real-time eligibility checks for Medicare.

Patients with active coverage will have a Medicare Advantage contract number and plan benefit identification information in their response. The information in the response will look like this example: H1234-001. It’s also important to verify their enrollment’s effective date and termination date.

Finally, confirm if the patient’s plan is on the list of participating plans. The list of active participating plans can be found on CMS’s model website or saved for reference via direct download. If the patient’s plan is part of the Hospice Benefit Component of the VBID model, follow the directions for submitting claims on the Billing/Payment webpage. For patients whose plan is not participating in the VBID model, submit their claims to Medicare as usual – there is no change needed.

For training on using your Inovalon software to follow VBID eligibility and submission requirements, please contact our support team.

Inovalon and design®, Inovalon®, and Inovalon are trademarks of Inovalon, Inc.

About the author

Michelle Karl, Solution Architect