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TMCNet:  Many Home Nutrition Patients Denied Medicare Reimbursement Despite Receiving A.S.P.E.N. Guidelines-Driven Treatment

[February 16, 2017]

Many Home Nutrition Patients Denied Medicare Reimbursement Despite Receiving A.S.P.E.N. Guidelines-Driven Treatment

Many home parenteral nutrition (HPN) patients who struggle to gain or maintain weight due to complex medical conditions may be falling through the cracks due to an outdated Medicare qualification process, suggests Option Care research being presented at the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Nutrition Week (CNW) conference. The study determined that Medicare coverage often doesn't match up with A.S.P.E.N. guideline recommendations, forcing patients to pay for some or all of their life-saving care.

Researchers found that more than half of HPN (intravenous) patients whose care met A.S.P.E.N. guidelines did not qualify for Medicare coverage. These findings suggest Medicare employs outdated HPN qualification criteria, including malnutrition diagnostic tools that do not reflect current recommended care.

"HPN is an expensive therapy and understandably Medicare wants to ensure that patients require that level of nutrition," said Natalie S. Tu, RD, lead author of the study and clinical nutrition support dietitian for Option Care. "However, many malnourished patients have a clear need for HPN but don't qualify for Medicare coverage. Care team members - including doctors and dietitians - need to diligently document the patient's need in an attempt to secure Medicare coverage."

In some cases, appeals providing additional documentation of need may be successful in securing coverage for patients initially denied by Medicare. Medicare patients who don't qualify for coverage pay out of pocket costs which can be up to $250 a day and are prohibitive for many people. The averge length of therapy for Option Care HPN patients is three months.1 Patients who have supplemental insurance may be partially covered, but will be required to pay a daily deductible, which also adds up.

Currently, about 20 percent of Option Care HPN patients have Medicare. That percentage will continue to increase as the population ages, underscoring the need for better alignment of Medicare coverage with A.S.P.E.N. guidelines, Tu said.

The Option Care study was named an A.S.P.E.N. CNW Abstract of Distinction for excellence and innovation. Researchers analyzed 142 patients receiving HPN, determining 49 (35 percent) met Medicare's HPN qualification criteria and 56 (39 percent) did not, while 37 (26 percent) did not move forward because the qualifying process was interrupted or incomplete. Of the 56 patients who did not qualify for Medicare, 31 (55 percent) did meet A.S.P.E.N. guideline recommendations.

Patients are prescribed HPN because they cannot meet their nutrition needs orally or via a tube feeding (enteral nutrition) due to conditions such as cancer, stroke, gastrointestinal disease or surgical complications. While HPN can be administered in the hospital, about 40,000 patients annually receive their nutrition therapy safely and with less cost at home, avoiding the risk of exposure to hospital-acquired infections, returning to work and living active lives.

Option Care's Nutrition Support Program follows a multidisciplinary team approach to care including infusion nurses, pharmacists and dietitians certified in nutrition support who work closely with physicians to provide the highest quality of care to home nutrition patients. Every Care Management Center is supported by a registered dietitian nationwide.

About Option Care

Option Care Enterprises, Inc. (Option Care) is one of the nation's largest and most trusted providers of home and alternate treatment site infusion services. An industry leader, the company draws on nearly 40 years of clinical care experience to offer patient-centered therapy management. Option Care's signature Home Infusion Plus services include the clinical management of infusion medicines, nursing support and care coordination. Option Care's multidisciplinary team of more than 1,800 clinicians - including pharmacists, nurses and dietitians - are able to provide home infusion service coverage for nearly all patients across the United States needing treatment for complex and chronic conditions. Learn more at www.OptionCare.com.

1. Option Care data on file.


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