OIG Releases Reports Regarding Hospice Claims and Medicare Coverage Requirements

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.

For more information on hospice organizations, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510, visit the Hospice Organizations specialty page, or the HLP Website

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