Home Health & Hospice Week

Don’t assume hospitalization equals GIP eligibility.

GIP has long been a target for medical review by Medicare contractors, but now the scrutiny may be kicking up a notch.

The HHS Office of Inspector General has listed “Audit of Selected, High-Risk Medicare Hospice General Inpatient Services” as a new item on its Work Plan. “The reimbursement rate for hospice general inpatient (GIP) care is the second-highest daily rate that Medicare pays for hospice services,” the OIG notes in the entry.

“We will focus on claims for enrollees who were transferred to GIP care immediately after an inpatient hospital stay for a period during which the enrollee’s inpatient stay reached or exceeded the geometric mean length of stay for the assigned diagnosis-related group,” the OIG explains. “These hospice GIP claims are at high risk for inappropriate billing because GIP care may exceed an enrollee’s needs or may not be provided.”

Bottom line: “We will determine whether hospice providers that billed for GIP care complied with Medicare requirements,” the OIG says. The agency expects to release a report on the topic in 2025, it indicates.

Watch out: “Because a hospice patient is receiving care in a hospital, certified hospice inpatient unit or Skilled Nursing Facility (SNF), which are the three locations for which GIP care can be billed under hospice, does not mean the services provided meet the GIP requirements,” the National Association for Home Care & Hospice cautions in its member newsletter. “The location of care is not the determining factor for the billable level of care,” NAHC explains.

“If the patient is in one of these facilities and is not receiving care that meets the GIP requirements, then the hospice must not bill the GIP level of care,” NAHC advises. “The hospice usually can bill the routine home care (RHC) level of care in these cases,” it adds.

Pitfall: “It should not be assumed that a patient being admitted to hospice from an acute hospital stay is eligible for the GIP level of care,” NAHC warns.

“The Work Plan addition is a continuation of the focus on hospice program integrity,” observes consulting firm The Health Group in Morgantown, West Virginia. “The concern is that hospices are appropriately billing for the level of care provided and not based on where the patient is physically located,” the firm notes in its electronic newsletter.

This new Work Plan item comes at the same time that the SEIU and NBC News have published criticisms of hospital chain HCA Healthcare allegedly pushing patients into hospice care inappropriately (see related story, p. 179).

“NAHC has heard from hospices that they sometimes feel pressure from hospitals to admit patients who are in their final days into hospice care so that the patient is excluded from the hospital’s mortality rate calculation,” it says.

But some safeguards against that exist. “Several entities other than the Centers for Medicare & Medicaid Services (CMS) calculate mortality rates such as US News & World Report and benchmarking entities. It is important to note that a hospitalized patient electing hospice care is excluded from some mortality rate calculations but not all,” NAHC offers.

Plus: “For the CMS measures in which hospice patients are excluded, patients are only excluded if they are enrolled in hospice prior to or on the first day of the hospital admission,” NAHC explains.

Bottom line: “CMS, the OIG and other oversight entities are holding the hospice accountable for correctly billing the level of care,” NAHC emphasizes.

Note: The Work Plan entry is at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000780.asp.