HHS I.G. Audit: 'Medicare Hospice Provider Compliance Audit – Professional Healthcare at Home, LLC'
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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 3,458 claims for which
What OIG Found
What OIG Recommends and Professional Healthcare Comments
We recommend that
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
Medicare Requirements ... 5
Terminal Prognosis Not Supported ... 6
RECOMMENDATIONS ... 6
PROFESSIONAL HEALTHCARE COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ... 7
Nonconcurrence With Recommendations ... 8
Professional Healthcare Comments ... 8
Concerns Related to Audit Process ... 9
Professional Healthcare Comments ... 9
Clinical Judgment and Support for Terminal Prognosis ... 10
Professional Healthcare Comments ... 10
Professional Healthcare Comments ... 11
APPENDICES
A: Audit Scope and Methodology ... 14
B:
C: Statistical Sampling Methodology ... 17
D: Sample Results and Estimates ... 18
E: Professional Healthcare Comments ... 19
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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
Medicare Requirements To Identify and Return Overpayments
OIG believes that this audit report constitutes credible information of potential overpayments. Upon receiving credible information of potential overpayments, providers must exercise reasonable diligence to identify overpayments (i.e., determine receipt of and quantify any overpayments) during a 6-year lookback period. Providers must report and return any identified overpayments by the later of: (1) 60 days after identifying those overpayments or (2) the date that any corresponding cost report is due (if applicable). This is known as the 60-day rule./17
The 6-year lookback period is not limited by OIG's audit period or restrictions on the Government's ability to reopen claims or cost reports. To report and return overpayments under the 60-day rule, providers can request the reopening of initial claims determinations, submit amended cost reports, or use any other appropriate reporting process./18
HOW WE CONDUCTED THIS AUDIT
We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.
Appendix A describes our audit scope and methodology, Appendix C describes our statistical sampling methodology, and Appendix D contains our sample results and estimates.
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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,
MEDICARE REQUIREMENTS
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
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. The face-to-face encounter must occur before, but no more than 30 calendar days before, the third benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. The narrative associated with the third benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. The physician or nurse practitioner who performs the face-to-face encounter must attest in writing that such an encounter occurred./25
TERMINAL PROGNOSIS NOT SUPPORTED
For 21 of the 100 sampled claims, the clinical record provided by
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/27 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.
PROFESSIONAL HEALTHCARE COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE
In written comments on our draft report,
independent medical review contractor repeatedly found that documentation was insufficient because it did not satisfy Local Coverage Determination (LCD) criteria.
After reviewing
Healthcare's statistical expert and maintain that our statistical sampling methodology and extrapolation were statistically valid and resulted in a legally valid and reasonably conservative estimate of the amount that Medicare overpaid to
Professional Healthcare Comments
* Regarding our first recommendation,
* Regarding our second recommendation,
* Regarding our third recommendation,
We clarified in the footnote to our first recommendation that OIG audit recommendations do not represent final determinations by Medicare. Action officials at CMS, acting through a MAC or other contractor, will determine whether a potential overpayment exists and will recoup any overpayments consistent with CMS's policies and procedures. If a disallowance is taken, a provider has the right to appeal the determination that a payment for a claim was improper (42 CFR Sec. 405.904(a)(2)). An overpayment based on extrapolation is re-estimated depending on the result of the appeal.
We maintain that our findings and recommendations are valid and that improper payment of the 21 sampled claims occurred because
CONCERNS RELATED TO AUDIT PROCESS
Professional Healthcare Comments
We selected
We used an independent medical review contractor that is a licensed physician who specializes in hospice and palliative medicine and is familiar with Medicare hospice guidelines and protocols. Although our independent medical review contractor referenced the ADEPT score in conducting the medical review, the contractor properly used the appropriate statutory and regulatory hospice criteria, as well as applicable LCD guidelines, as the framework for determining terminal status. Specifically, our independent medical review contractor applied standards set out in 42 CFR Sec. 418.22(b)(2), which requires that clinical information and other certification of terminal illness and be filed in the medical record./29
We acknowledge that some beneficiaries who did not meet the guidelines in the hospice LCDs may still be appropriate for hospice care based upon an individual assessment of the beneficiary's health status. Accordingly, our independent medical review contractor merely used LCD guidelines as a tool to evaluate the terminal prognosis. In conclusion, it was the opinion of our contractor that the documentation in the clinical records did not support the terminal prognosis. Therefore, we maintain that our independent medical review contractor consistently and appropriately applied Medicare hospice eligibility requirements when it determined whether the certified terminal prognosis was supported.
CLINICAL JUDGMENT AND SUPPORT FOR TERMINAL PROGNOSIS
Professional Healthcare Comments
As previously mentioned, we used an independent medical review contractor that is a licensed physician who specializes in hospice and palliative medicine and is familiar with Medicare hospice guidelines and protocols. In conducting the medical review, our contractor properly used the appropriate statutory and regulatory hospice criteria, as well as applicable LCD guidelines, as the framework for its determinations. Our contractor acknowledged the physician's terminal diagnosis and evaluated the clinical records provided by the hospice for each sampled claim (including necessary historical clinical records), guided by questions rooted in the Medicare requirements, to determine whether the certified terminal prognosis was supported. When the clinical records and other available clinical information supported the physician's medical prognosis of a life expectancy of 6 months or less if the terminal illness runs its normal course, a determination that hospice eligibility criteria were met was made. In addition, the decisions in the court cases that
Based on our review of
OFFICE OF INSPECTOR GENERAL SAMPLING METHODOLOGY
Professional Healthcare Comments
After reviewing the statistical expert's report, we maintain that our sampling methodology and extrapolation are statistically valid. The legal standard for use of sampling and extrapolation is that it must be based on a statistically valid methodology, not the most precise methodology./30
We properly executed our statistical sampling methodology in that we defined our sampling frame and sample unit, randomly selected our sample, applied relevant criteria in evaluating the sample, and used statistical sampling software (i.e., the OIG,
The statutory and manual requirement that a determination of a sustained or high level of payment errors must be made before extrapolation can be used applies only to Medicare contractors--not OIG./31
In addition, OIG no longer uses the 5-percent error-rate threshold in its CIAs. Moreover, even in prior CIAs that used the 5-percent error-rate threshold, the threshold was used to determine when an additional claims sample (referred to as a "full sample") needed to be selected and reviewed based on the results of a probe sample (referred to as a "discovery sample"). The entity under the CIA was required to extrapolate the results of the full sample, regardless of the error rate./32
More generally, OIG may perform a statistical or non-statistical review of a provider without covering all claims from that provider.
Furthermore, OIG's statistical estimates are applied only to the sampling frame from which the sample was drawn.
To account for the precision of our estimate, we recommend recovery at the statistical lower limit of a two-sided 90-percent confidence interval. Lower limits calculated in this manner are designed to be less than the actual overpayment total in the sampling frame 95 percent of the time. The use of the lower limit accounts for the precision of our estimate in a manner that generally favors the auditee./34
Healthcare refund a larger amount to the Government.
We provided
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View full report at https://oig.hhs.gov/oas/reports/region9/91803028.pdf
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