Home Health & Hospice Week

VITAS audit’s drastic findings could taint industry.

The OIG Semiannual Report to Congress takes on hospice fraud as well, and the potential consequences are also dire.

A 20 percent cut to the aggregate per patient hospice cap is on the table for hospices as the year winds down, national advocacy groups report. Whether lawmakers will pull the trigger on the change may depend on what information they see, including from the HHS Office of Inspector General.

For hospice, the OIG focuses on two recent hospice audit reports in its Semiannual Report released Dec. 5.

Audit No. 1: The OIG found that VITAS Healthcare Corp. of Florida did not comply with Medicare requirements for 89 of the 100 claims in its sample. “VITAS’ policies and procedures were not effective to ensure that it maintained documentation to support the level of care and hospice services claimed for Medicare reimbursement,” the report says. The OIG estimates that VITAS received “at least $140 million in improper Medicare reimbursement for hospice services that did not comply with Medicare requirements.”

However, in a 21-page response letter penned by its counsel, attorney Bryan Nowicki with law firm Husch Blackwell, VITAS blasted the findings of the audit that focused on General Inpatient and Continuous Home Care levels of care. In its own evaluation, “VITAS confirmed that its patient records supported the reasonable clinical judgments of the physicians who determined each patient’s appropriate level of hospice care,” the response letter said. “Moreover, VITAS has identified substantial and fundamental flaws in the OIG’s medical review and audit process,” it charged.

Audit No. 2: In its review of 100 claims from Hospice of Palm Beach County Inc. in West Palm Beach, Florida, the OIG found 40 claims noncompliant and assessed a resulting $42.3 million overpayment. “HPBC’s policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis, that the appropriate level of care was provided, and that services were supported,” the OIG says in the Semiannual Report.

In a sometimes-blistering response letter also signed by Nowicki, HPBC dismissed the OIG’s findings. For example, “if OIG’s conclusion were correct, it would mean that the clinical judgment of over 28 different certifying physicians, who personally treated the patients and had absolutely no incentive to improperly admit them for hospice care, was incorrect,” the response letter noted (see HHHW, Vol. XXXI, No. 35).

The Semiannual Report also makes yet another mention of the OIG’s push to prorate hospital DRG payments when patients are discharged early to post-acute care. Discharges to hospice qualify for those prorations as of 2019, the OIG notes in the report.