OIG Report Blasts Hospice & CMS Oversight

A recently released OIG report blasts hospices and CMS for lack of oversight.  The report detailed multiple instances, totaling 16 different areas, in which CMS and providers failed to comply with established regulations.

The report indicates that since 2012, the OIG has opened over 200 cases involving fraud related to hospice providers. Noting this aspect of the report is important because such a release usually leads to increases in OIG activity.  OIG activity usually includes more compliance audits and will likely lead to charges. These activities and charges usually begin to be picked up by lawmakers who then begin to draft legislation on curtailing activities.

Home health agencies began to receive this scrutiny about 10 years ago when the OIG and national media began picking up on the profit margins of publicly traded companies.  What we saw were congressional hearings and resulting legislation that stripped home health agencies of most of their profitability, increased compliance, and continued pressure to meet new regulatory compliance measures.

This year’s investigation continues to build on the 2012 report, but also focuses on many new issues discovered.  Out of the 16 noted issues, CMS agreed with only 6 of the OIG’s findings which is somewhat comforting for providers because that means a new slew of regulations will not be implemented.  However, the OIG operates as an independent body of CMS and does not need CMS’ permission to act or move forward with any types of audits or compliance measures.

Inappropriate Billing

The OIG has identified hospices are routinely misidentifying the appropriate levels of care provided to patients who elect the hospice benefit. Overbilling has cost an estimated $268 million. The report goes on to say that certifications are missing or incomplete and incomplete documentation for the services that were provided to patients.

Insufficient Care Planning and Poor Quality Care

Citing information from 2012 and following up in the new report, the OIG estimates that 85% of all hospices did not meet the patient’s plan of care. The report goes on to state that patients did not receive all required services or appropriate services as needed.  Usually the services required vs. services provided were much lower.  Utilizing claim data, OIG made a determination that weekends were very susceptible to less than adequate care.

Fraudulent Enrollment and Non-Compliant Certifications

The OIG discovered many instances in which hospice patients were enrolled for hospice benefits that were not eligible for the service.  This admission points directly back to CMS and the Intermediaries for not having systems in place to reject billings and NOEs for patients that are not covered.  While providers who fraudulently bill for these services knowing the patients don’t qualify, CMS bares a big part of the blame for allowing this to occur and not stopping it.

Physicians who do not properly certify patients occurred 14% of the time based on information reviewed. This issue could easily be corrected with more education from hospices to physicians and identifying the issues sooner rather than later.

Hospice Elections and Public Information Reporting

OIG’s report identified several deficiencies with the information that was provided to patients.  The report sites examples that include inappropriate enrollment and the main complaint, information on how the hospice election affects a patient’s access to care and other benefits.

The OIG goes on further to state that the public should have more access to survey results, complaints, and enforcement action against providers.  OIG believes that consumers should be able to read, review, and understand all issues related to providers to help allow consumers to choose the appropriate hospice for their needs.

To combat what OIG believes is systematic and possible rampant abuse, CMS agreed to look into six areas that it believes will greatly strengthen the integrity of the hospice benefit.

  1. Develop claims-based information to include on Hospice Compare (more transparency and information for consumer’s choice).
  2. Expand educational offerings to hospitals and patient advocacy groups so that consumers are more aware of the hospice benefit and what the service provides.
  3. Analyze claim data to determine which hospices may be engaging in non-compliant or possibly fraudulent behavior.
  4. Continue to follow up with hospices that are deemed to be engaging in possible non-compliant behavior.
  5. Continue to closely monitor inpatient SNF care for appropriate billing and to ensure the appropriate level of care is actually necessary for the patient and it meets the patient’s medical characteristics.
  6. Develop a comprehensive prepayment review strategy that ensures patients are not enduring long periods of time when pain and symptoms are not being controlled.

Hospices should be prepared for increased compliance audits and ADRs, record reviews, and other compliance programs being rolled out. Frequently the OIG works with other law enforcement and investigators within the Department of Justice.

Hospices should begin to review their internal compliance programs, develop new educational programs for clinical and office staff, and focus on more detailed chart reviews.  Providers need to make sure that every “i” is dotted and every “t” is crossed. Providers that continue to make QA a strong focus of their agency will have a better result should an audit or issue arise.

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