Home Health & Hospice Week

Start your self-audits before you see penalties.

Hospices should learn a lesson from home health agencies’ journey and expect an increasing burden of medical review and regulatory requirements, a new report indicates.

In its newly released “Compendium of Unimplemented Recommendations,” the HHS Office of Inspector General lists a number of actions it urges HHS and the Centers for Medicare & Medicaid Services to take to curb hospice fraud, abuse, and waste.

“The hospice industry is coming under greater and greater scrutiny,” stresses attorney Robert Markette Jr. with Hall Render in Indianapolis. “Hospice providers should look at what has happened to their colleagues in home health and begin to focus heavily on compliance,” Markette urges.

Hospices should pay particular attention to the areas the OIG highlights in its recommendations:

• • reformed hospice payments to reduce the incentive for hospices to target beneficiaries with certain diagnoses and those likely to have long stays;
• • more frequent surveys;
• • a hospital transfer payment policy for early discharges to hospice care;
• • modification of payment for nursing home
• residents receiving hospice;
• • stepped-up monitoring for nursing home residents receiving hospice;
• • increased oversight of General Inpatient (GIP) claims;
• • “additional enforcement remedies for poor hospice performance”;
• • new physician documentation requirements for GIP;
• • prepayment reviews for lengthy GIP stays;
• • enhanced survey focus on care planning requirements;
• • scrutiny of separate Part D payments for hospice patients’ drugs;
• • education on hospice revocations and discharges; and
• • strengthened surveyor review of election statements and certifications of terminal illness.

The OIG gives special emphasis to the hospital stay proration recommendation and the payment reform suggestion, ranking them both in its top 25 unimplemented recommendations.

Referral deterrent: “Establishing a transfer payment rate policy for early discharges to hospice care would have saved Medicare approximately $602.5 million in 2009 and 2010,” the OIG estimates.

In other words, hospitals would have received $600 million less reimbursement unless they delayed hospice referral past the proration point.

“CMS should change its regulations or pursue a legislative change, if necessary, to establish a hospital transfer payment policy for early discharges to hospice care,” the OIG urges. CMS said it would consider implementing the policy, but to date hasn’t proposed it in a hospital payment system rule, the report notes.

Payment Reform Doesn’t Go Far Enough, OIG Maintains

The OIG reiterates that it has “identified hospice billing patterns suggesting that Medicare’s current payment system may not align with the needs of hospice patients. We found that hospices might be targeting beneficiaries to achieve the greatest financial gains.”

CMS agreed with this conclusion, and implemented changes in January 2016 to address the problems, the OIG acknowledges. The new payment structure includes a higher base rate for the first 60 days and a Service Intensity Add-on for registered nurse and social worker visits that occur in the last seven days of life.

But “in OIG’s view, the new structure … does not resolve all aspects of our recommendation,” the report says. “OIG does not consider the new payment structure to be the best way to align payments with patient needs because it does not address the vulnerability of hospices targeting beneficiaries to achieve the greatest financial gains.”

Areas ripe for cherry-picking are long-stay patients and benes in assisted living facilities, for example.

“CMS should consider options that tie the specific needs of the beneficiary to payment rates,” the OIG urges. In other words, a straight-up case mix system.

“In areas where billing incentives exist, CMS should improve oversight of incentivized behaviors, such as lengthened inpatient stays or increased billing by for-profit hospices,” the OIG continues.

What’s ahead: “As hospice utilization and spending continue to grow, CMS is going to continue to look more and more at hospice,” Markette predicts. “Hospice will find the experience as unpleasant as home health has found it,” he says.

An example: “I am already seeing [Unified Program Integrity Contractor] AdvanceMed begin to audit hospice providers with a greater frequency,” Markette tells Eli.

Do this: Hospices can’t sit back to wait and see how the increase scrutiny affects them. “Hospice providers need to look at the area(s) mentioned in this report and the last few OIG workplans and begin auditing their own performance in that area,” Markette recommends. “Identifying and correcting your mistakes before OIG/auditors is an extremely important effort to avoid significant penalties and other negative impacts.”

Note: See the compendium at https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2017.pdf. Access the OIG workplans at https://oig.hhs.gov/reports-and-publications/workplan.