Hospice Providers Face Claims Scrutiny

Hospice providers are facing ongoing claims scrutiny, highlighting the importance of compliance. On June 8, 2010, the Centers for Medicare and Medicaid Services (“CMS”) held a national outreach session to educate hospice providers regarding specific vulnerabilities involving hospice services, with specific emphasis on the provision of hospice services to beneficiaries residing in nursing facilities.

Two recent Office of Inspector General (“OIG”) documents highlight this important issue. First, in September 2009, the OIG published a report entitled, “Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements.” This OIG report concludes that 82 percent of hospice services provided to beneficiaries in nursing facilities in 2006 failed to meet Medicare coverage requirements. The report found that most deficiencies were related to the hospice’s failure to comply with provisions of the hospice plan of care, failure to obtain valid hospice election statements, and failure to comply with hospice certification requirements. The report states that the information contained therein would be shared with the Recovery Audit Contractors (“RACs”); accordingly, providers may expect that the RACs may target hospices in conducting claims reviews.

A second OIG document entitled, “Medicare Hospice Care: Services Provided to Beneficiaries Residing in Nursing Homes,” details the increase in hospice services provided to beneficiaries residing in nursing homes over time. The document further notes the high percentage of hospice patients that reside in nursing facilities who have ill-defined conditions or mental diseases (e.g., Alzheimer’s disease, chronic obstructive pulmonary disease (“COPD”), unspecified heart disease, etc.).

These documents, together with the recent educational sessions put on by CMS, highlight the scrutiny under which hospice claims will be reviewed. Accordingly, it is imperative that hospice providers adopt and implement appropriate compliance procedures, not only with respect to technical issues (e.g., plan of care, election and certification requirements), but also with respect to eligibility issues (e.g., fully documenting a given patient’s condition and signs and symptoms of decline to establish hospice eligibility, taking into account published Medicare policy guidance and local coverage decisions).

For more information regarding the above-referenced reports or with respect to hospice services in general, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510.

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