HHS I.G. Audit: 'Medicare Hospice Provider Compliance Audit – Northwest Hospice, LLC'
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Report in Brief
Here are excerpts:
Why OIG Did This Audit
The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care. Previous OIG audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.
Our objective was to determine whether hospice services provided by
How OIG Did This Audit
Our audit covered 6,864 claims for which
What OIG Found
What OIG Recommends and NW Hospice Comments
We recommend that
In written comments on our draft report,
After reviewing
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TABLE OF CONTENTS
INTRODUCTION ... 1
Why We Did This Audit ... 1
Objective ... 1
Background ... 1
The Medicare Program ... 1
The Medicare Hospice Benefit ... 1
Medicare Requirements To Identify and Return Overpayments ... 3
How We Conducted This Audit ... 4
FINDING ... 5
Terminal Prognosis Not Supported ... 5
RECOMMENDATIONS ... 6
NW HOSPICE COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ... 6
Hospice Discharges Within the Margin for Reasonable Clinical Judgment and Support for Terminal Prognosis ... 7
NW Hospice Comments ... 7
The 60-
NW Hospice Comments ... 9
Recommendations ... 9
NW Hospice Comments ... 9
APPENDICES
A: Audit Scope and Methodology ... 11
B:
C: Statistical Sampling Methodology ... 14
D: Sample Results and Estimates ... 15
E: NW Hospice Comments ... 16
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INTRODUCTION
WHY WE DID THIS AUDIT
The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care. Previous
OBJECTIVE
Our objective was to determine whether hospice services provided by
BACKGROUND
The Medicare Program
Title XVIII of the Social Security Act (the Act) established the Medicare program, which provides health insurance coverage to people aged 65 and over, people with disabilities, and people with end-stage renal disease. The
Medicare Part A, also known as hospital insurance, provides for the coverage of various types of services, including hospice services.2 CMS contracts with Medicare Administrative Contractors (MACs) to process and pay Medicare hospice claims in four home health and hospice jurisdictions.
The Medicare Hospice Benefit
To be eligible to elect Medicare hospice care, a beneficiary must be entitled to Medicare Part A and certified by a physician as being terminally ill (i.e., as having a medical prognosis with a life expectancy of 6 months or less if the illness runs its normal course)./3
Hospice care is palliative (supportive), rather than curative, and includes, among other things, nursing care, medical social services, hospice aide services, medical supplies, and physician services. The Medicare hospice benefit has four levels of care: (1) routine home care, (2) general inpatient care, (3) inpatient respite care, and (4) continuous home care. Medicare provides an all-inclusive daily payment based on the level of care./4
Beneficiaries eligible for the Medicare hospice benefit may elect hospice care by filing a signed election statement with a hospice./5
Upon election, the hospice assumes the responsibility for medical care of the beneficiary's terminal illness, and the beneficiary waives all rights to Medicare payment for services that are related to the treatment of the terminal condition or related conditions for the duration of the election, except for services provided by the designated hospice directly or under arrangements or services of the beneficiary's attending physician if the physician is not employed by or receiving compensation from the designated hospice./6
The hospice must submit a notice of election (NOE) to its MAC within 5 calendar days after the effective date of election. If the hospice does not submit the NOE to its MAC within the required timeframe, Medicare will not cover and pay for days of hospice care from the effective date of election to the date that the NOE was submitted to the MAC./7
Beneficiaries are entitled to receive hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods./8
At the start of the initial 90-day benefit period of care, the hospice must obtain written certification of the beneficiary's terminal illness from the hospice medical director or the physician member of the hospice interdisciplinary group/9 and the beneficiary's attending physician, if any. For subsequent benefit periods, a written certification by only the hospice medical director or the physician member of the hospice interdisciplinary group is required./10
The initial certification and all subsequent recertifications must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less./11
The written certification may be completed no more than 15 calendar days before the effective date of election or the start of the subsequent benefit period./12
A hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice beneficiary whose total stay across all hospices is anticipated to reach a third benefit period./13
The physician or nurse practitioner conducting the face-to-face encounter must gather and document clinical findings to support a life expectancy of 6 months or less./14
Hospice providers must establish and maintain a clinical record for each hospice patient./15
The record must include all services, whether furnished directly or under arrangements made by the hospice. Clinical information and other documentation that support the medical prognosis of a life expectancy of 6 months or less if the terminal illness runs its normal course must be filed in the medical record with the written certification of terminal illness./16
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FINDING
On the basis of our sample results, we estimated that
As of the publication of this report, these overpayments include claims outside of the 4-year reopening period./22
Notwithstanding,
TERMINAL PROGNOSIS NOT SUPPORTED
To be eligible for the Medicare hospice benefit, a beneficiary must be certified as being terminally ill. Beneficiaries are entitled to receive hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods. At the start of the initial 90-day benefit period of care, the hospice must obtain written certification of the beneficiary's terminal illness from the hospice medical director or the physician member of the hospice interdisciplinary group and the individual's attending physician, if any. For subsequent benefit periods, a written certification from the hospice medical director or the physician member of the hospice interdisciplinary group is required. Clinical information and other documentation that support the beneficiary's medical prognosis must accompany the physician's certification and be filed in the medical record with the written certification of terminal illness./24
For 19 of the 100 sampled claims, the clinical record provided by
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RECOMMENDATIONS
We recommend that
* refund to the Federal Government the portion of the estimated
* based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule/26 and identify any of those returned overpayments as having been made in accordance with this recommendation; and
* strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.
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View full report at https://oig.hhs.gov/oas/reports/region9/92003035.pdf
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