Health Law Attorney Blog

Last week, the OIG released it's Compendium of Unimplemented Recommendations that "consolidates significant unimplemented monetary and nonmonetary recommendations addressed to the Department of Health & Human Services (HHS) to provide information to interested parties about outstanding recommendations...." While these have not been implemented, it is something we want our clients and readers to be aware of. It shows the direction the OIG is going and where it is focusing its efforts. Some relevant recommendations are below:

Hospices:
1. Due to the high number of hospices that were overdue in their certifications and due to the almost 50% of hospices having health deficiencies, the OIG recommends that CMS adopt statutory or regulatory changes to establish requirements for the frequency of certifications for hospice performance and for enforcing the remedies for a hospice's poor performance.
2. The OIG recommends that CMS strengthens its monitoring practices of hospice claims to ensure that they are properly submitted.

Home Health Agencies:
1. Due to the high levels of medically unnecessary care and fraudulent billing, the OIG recommends that CMS revise its regulations to require physicians to examine Medicare beneficiaries prior to ordering home health services.
2. For those HHAs performing poorly, the OIG recommends that CMS adopt and impose sanctions (besides termination from Medicare) to improve the quality of care.

Laboratory and Imaging Services:
1. To prevent over-utilization of laboratory testing, the OIG recommends that CMS reinstate beneficiary co-insurance and deductibles for lab tests.
2. The OIG recommends that CMS pursue legislation to set accurate and reasonable payment rates for lab tests as the carrier rates for nearly all lab tests varied.
3. Because few counties account for a large percentage of the Part B spending on ultrasound and because 20% of claims raised concern about whether or not they were appropriate, OIG recommends that CMS continue to monitor ultrasound claims to reduce Medicare's vulnerability to questionable ultrasound claims.

Again, these are merely recommendations and have not been implemented. However, they are useful in seeing where the OIG is looking to make changes and what kinds of changes we can expect from CMS in the future. We will continue to keep you apprised of any updates and regulatory changes as they develop.

Continue reading "OIG Releases Compendium of Unimplemented Recommendations" »

All too often, services provided by hospices are denied by Medicare due to incomplete or inaccurate documentation practices that can easily be prevented.  A September report by the HHS Office of Inspector General analyzed some of the most common documentation inadequacies in hospice services provided to beneficiaries at nursing facilities, and the statistics are surprising.
 
According to the OIG report, the following mistakes were made: In 33 percent of claims, the election statement was either missing or failed to meet election statement requirements.  The most frequent problem was a failure to fully explain that the goal of hospice is palliative, not curative--meaning that beneficiaries are waiving certain services related to their terminal illnesses.  In 63 percent of claims, plans of care were inadequate--lacking an interdisciplinary approach or leaving out the scope of treatment or other requirements.  In 31 percent of claims, the services provided did not match the services outline in the plan of care.  In only 4 percent of cases was the problem certification, and in some of those cases, the issue was a failure to obtain a physician signature. 
 
In total, a startling 81 percent of claims in the OIG's study sample did not completely meet coverage requirements.

Continue reading "OIG Report Found 81% of Hospice Claims Failed to Meet Documentation Requirements" »

When a beneficiary elects hospice care, s/he waives any Part B coverage related to that hospice care except for services rendered by an "attending physician." An attending physician is defined as either a doctor of medicine, doctor of osteopathy or a nurse practitioner who is identified by the beneficiary as having the most significant role in the beneficiary's determination and delivery of medical care.

The beneficiary may designate and use an attending physician, who is not employed by the hospice, for professional services furnished in addition to the services of hospice-employed physicans. The professional services of an attending physician that are reasonable and necessary for the treatment and management of a hospice patient's terminal illness are not considered hospice services. Provided he or she does not furnish the services under a payment arrangement with the hospice, the services of the attending physician are billed to Medicare Part B with the GV modifier-- "Attending physician not employed or paid under agreement by the patient's hospice provider." If a substitute or locum tenens physician provides services, the services are billed by the designated attending physician under the reciprocal or locum tenens billing instructions by use of modifier GV in conjunction with either the Q5 or Q6 modifier. Payment is made to the attending physician or beneficiary, as appropriate, based on the payment and deductible rules applicable to each covered service. Services not related to the hospice patient's terminal condition are coded with the GW modifier--"Service not related to the hospice patient's terminal condition."

If a private attending physician furnishes services related to a hospice patient's terminal condition under a payment arrangement with the hospice, such services are considered "hospice services" and are billed by the hospice to Medicare Part A. Hospice physician services are paid by the hospice intermediary, Part A, at 100% of Medicare approved charges.

Continue reading "Billing Claims Involving Hospice Coverage" »

OIG released two reports examining the hospice benefit for residents of a nursing care facility. The first report, "determined the extent to which hospice claims for beneficiaries in nursing facilities met Medicare coverage requirements." According to Section 418 of Title 42 of the Code of Federal Regulation, to receive Medicare coverage for delivering hospice care services, Medicare requires that
- The services be reasonable and necessary;
- Hospice care is elected pursuant to the applicable regulations;
- Prior to delivering any hospice services, a plan of care is established;
- The hospice services provided are within that established plan of care; and
- The patient has a certification that the illness is terminal.

The OIG's report revealed that a large percentage of hospice claims do not meet these requirements. More specifically, the report found that 82% of hospice claims did not meet at least one of the aforementioned requirements, resulting in Medicare paying $1.8 billion for these claims. Of this 82%, 63% of the claims failed to meet the requirement that a plan of care be established; 31% of the claims did not provide the services detailed in the plan of care; and 4% of the claims failed to meet the requirement that the patient's illness be terminal.

As a result of this study, the OIG has recommended that CMS develop better methods of educating hospices and providing them guidance on Medicare coverage requirements for hospice care services. Furthermore, the OIG recommends that CMS increase its monitoring of hospice care claims to "effectively use targeted medical reviews and other oversight mechanisms to improve hospice performance and compliance with Medicare requirements...." CMS agreed with all of the recommendations.

The second report OIG released pertaining to hospices examines hospice care services in nursing facilities. The study found that the percentage of hospice beneficiaries in nursing facilities increased by 3% from 2005 to 2006. In 2006, Medicare paid $2.59 billion for such services, averaging $960 per week per beneficiary (this does not include the physician services). Furthermore, the OIG found that the services hospices most commonly furnished included nursing services (96% of claims), home health aide (73% of claims), and medical social services (68% of claims). For these services, combined, the OIG found that hospices provided an average of 4.2 visits per week.

The purpose of this report was to raise awareness to CMS. The OIG did not have any recommendations or opinions on its findings.

Continue reading "OIG Releases Reports Regarding Hospice Claims and Medicare Coverage Requirements" »