OIG Issues Report Finding Inconsistencies in Medicare Billing for Hospice Inpatient Stays

On May 3, 2013, the US Department of Health and Human Services Office of the Inspector General’s (OIG) Office of Evaluation and Inspections (OEI) issued a report (OEI-02-10-00490) entitled “Medicare Hospice:  Use of General Inpatient Care.”  The report found that while Medicare paid $1.1 billion for hospice general inpatient care (“GIP”) in 2011, there were unusual Medicare billing patterns for hospice inpatient stays, raising concerns about whether the stays were billed appropriately and whether the patients received the right level of care.

Medicare hospice is designed to provide comfort for patients with six months to live.  Hospice GIP is intended to treat pain and other symptoms in an inpatient facility that cannot be managed in other hospice settings.  While the care is short-term, it is the second most expensive level of hospice care covered by Medicare.  The OIG said questions were expressed about the care and length of stay during GIP, and that most of the $1.1 billion spent by Medicare for GIP in 2011 was for care provided in Medicare-certified hospice inpatient units, and not in hospitals or in skilled nursing facilities (“SNFs”).

The OIG did not find definitive evidence of inpatient care misuses, but said inconsistencies in billing for GIP among hospices warrants further investigation to ensure that hospices are using GIP as intended and providing the appropriate level of care.  Specifically, the OIG found that hospices that owned or leased their own inpatient units provided GIP care to more beneficiaries and for longer periods of time than those without.  Hospices that used inpatient units provided GIP to 35% of their beneficiaries, while those who did not provide GIP in for only 12% of their beneficiaries.  The hospices that used inpatient units also had GIP representing 13% of their total Medicare dollars, while those that did not use inpatient units had GIP representing only 4% of their total Medicare dollars.  Hospices that provided GIP in inpatient units were also found to be more likely to be large than were other hospices that provided GIP.

Additionally, GIP stays in inpatient units were found to be typically longer than GIP stays in other settings.  Generally, Medicare policy does not specify a limit on the number of days GIP is allowed, although it is intended to be short-term.  One-third of beneficiaries’ GIP stays exceeded five days, with 11% lasting ten days or more.  On average, GIP stays in inpatient units were found to be 50% longer than GIP stays in hospitals and 29% longer than GIP stays in SNFs.  Also, while the OIG expected percentages of GIP that start during weekend days and those that start during weekdays to be similar since GIP is meant for paint control or symptom management, it found that a greater percentage started on weekdays, with the lowest percentage starting on Sundays.

The OIG Report also found that 27% of Medicare hospices did not provide GIP in 2011, and often did not provide other levels of hospice care including continuous care and inpatient respite care which are covered by Medicare and must be provided if needed.  Notably, the beneficiaries of these Medicare hospices had the same terminal illnesses as beneficiaries served by hospices that provided GIP.  Significantly, the hospices that did not provide GIP were more likely than other hospices to be for-profit, and more likely to be small (i.e., provided hospice care to 90 or fewer Medicare beneficiaries in 2011).

This report was based on an analysis of Medicare hospice claims.  The follow-up study, which will use actual patient medical records to look for reimbursement irregularities, is ongoing.

As a result of this study, the OIG found that long lengths of stay and the use of GIP in inpatient units need further review to ensure that hospices are using GIP as intended and providing the appropriate level of care.  Further, the report advised that CMS should focus on these issues as it considers options for hospice payment reform and for developing hospice quality measures.

You can find a copy of the OIG report here —> OEI-02-10-00490

For more information on the OIG Report, Medicare Program Integrity initiatives, hospice fraud and abuse issues, or related issues, please feel free to contact Daniel Meier or any member of our health care practice group for a further discussion.

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