Home Health & Hospice Week

A factor you may not have much control over could land you on the feds' radar screen.

The HHS Office of Inspector General examines physician Part B billing for hospice patients in a new report. The OIG singles out claims that physicians submitted for patients on the hospice benefit, when the hospice also submitted claims containing that physician's services for the patient.

Criteria: The overlapping hospice and physician claims had to have the same primary diagnosis and physician, but claims with the GW modifier (indicating the services weren't related to the  terminal illness) were excluded.

Out of $165 million Medicare paid physicians for services to hospice beneficiaries in 2009, about $566,000 was "questionable," the OIG says in the report. About one-third of the 9,272 questionable claims for 4,280 beneficiaries were from Florida.

The Florida claims amounted to $199,613, 35 percent of the total questionable reimbursement. North Carolina had the next highest amount, with $63,027 in questionable claims -- 11 percent of the total.

In comparison, Florida has 9 percent of the program's hospice benes and North Carolina has 3 percent.

Modifier misuse? In nearly 70 percent of the questionable claims, the physician indicated with the GV modifier that she was not employed or paid under agreement by the patient's hospice provider. "It is not clear in these cases whether the physician used the modifier incorrectly or the hospice billed inappropriately," the OIG concludes.

The most common diagnoses for the questionable claims were lung cancer, chronic airway obstruction, and congestive heart failure, the OIG says. The most common physician services were for patient evaluation and management.

"Although we did not find that this problem is widespread, billing for physician services for hospice care is a potential program vulnerability given that Medicare may be billed under Part Aand Part B," the OIG says. "We encourage [the Centers for Medicare & Medicaid Services] to continue to monitor this issue."

The OIG examined the issue in part because CMS listed it as a top concern.