The Office of Inspector General (“OIG”) for the U.S. Department of Health and Human Services has issued a report finding a “number of instances” in which hospices inappropriately billed Medicare for hospice general inpatient care (“GIP”). According to the OIG, misuse of GIP included care being billed but not provided and beneficiaries receiving care they did not need.
The OIG report indicated that this “misuse” had human costs as well as financial costs for Medicare. It noted that the goals of hospice care were to help terminally ill beneficiaries with a life expectancy of six months or less to continue life with minimal disruptions and to support beneficiaries' families and other caregivers; the care “is palliative, rather than curative.”
Hospices must establish an individualized plan of care for each beneficiary, the OIG observed, adding that GIP “is the second most expensive level of hospice care and is intended to be short-term inpatient care for symptom management and pain control that cannot be handled in other settings.”
The OIG report found that hospices billed one-third of GIP stays inappropriately, costing Medicare $268 million in 2012. It found that hospices “commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms.”
For example, according to the OIG report, a hospice billed for GIP for a beneficiary with a circulatory disease who had no unmanaged symptoms. This beneficiary could have been cared for at home, but the hospice billed Medicare for 46 consecutive days of GIP. The hospice was paid just over $31,000 for the stay.
The report noted that some states, such as Florida, had “many inappropriate GIP stays.” According to the report, hospices were more likely to inappropriately bill for GIP provided in skilled nursing facilities than GIP provided in other settings and for-profit hospices were more likely than other hospices to inappropriately bill for GIP. The report also found that Medicare sometimes paid twice for drugs because they were paid for under Part D when they should have been provided by the hospice and covered under the hospice daily payment rate. Further, the report found, hospices did not meet all care planning requirements for 85 percent of GIP stays and sometimes provided poor quality care. As an example, the report cited one hospice that provided GIP to a beneficiary with dementia for 16 days, but his pain was never brought under control.
The OIG report concluded that there was a need to address the misuse of GIP and to hold hospices accountable when they billed inappropriately or provided poor quality care. The OIG report recommended that the Centers for Medicare & Medicaid Services (“CMS”):
(1) increase its oversight of hospice GIP claims and review Part D payments for drugs for hospice beneficiaries;
(2) ensure that a physician is involved in the decision to use GIP;
(3) conduct prepayment reviews for lengthy GIP stays;
(4) increase surveyor efforts to ensure that hospices meet care planning requirements;
(5) establish additional enforcement remedies for poor hospice performance; and
(6) follow up on inappropriate GIP stays, inappropriate Part D payments, and hospices that provided poor-quality care.
The CMS concurred with all six recommendations.
Learn more: OIG Report.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].