Hospice pricing

Hospice programs are not eligible for TRICARE reimbursement unless they enter into an agreement with TRICARE. National Medicare hospice rates will be used for reimbursement of each of the following levels of care provided by, or under arrangement with, a Medicare-approved hospice program:

  • Routine home care
  • Continuous home care
  • Inpatient respite care
  • General inpatient care

The national Medicare payment rates are designed to reimburse the hospice for the costs of all covered services related to the treatment of the beneficiary’s terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of, or working under arrangements made with, the hospice. The only amounts that will be allowed outside of the locally adjusted national payment rates and not considered hospice services will be for direct patient-care services rendered by either an independent attending physician or a physician under contract with the hospice program.

When billing, hospices should keep in mind the following:

  • Bill for physician charges/services (physicians under contract with the hospice program) on a UB-04 claim form using the appropriate revenue code of 657 and the appropriate CPT codes
  • Payments for hospice-based physician services will be paid at 100 percent of the TRICARE allowable charge and will be subject to the hospice cap amount (calculated into the total hospice payments made during the cap period)
  • Bill independent attending physician services or patient-care services rendered by a physician not under contract with or employed by the hospice on a CMS-1500 claim form using the appropriate CPT codes. These services will be subject to standard

TRICARE reimbursement and cost-sharing/deductible provisions will not be included in the cap amount calculations.