Eli's Hospice Insider

Tip: Document GIP trigger.

Both the feds and employees bringing whistleblower lawsuits have been focusing on General Inpatient care. Protect yourself from GIP claim denials and legal action as scrutiny of this service ramps up.

In a May 24 hearing before the House Energy & Commerce Subcommittee on Oversight and Investigations, HHS Assistant Inspector General Ann Maxwell pointed out problems with GIP. “Hospices inappropriately billed Medicare over $250 million for general inpatient care,” she said, referencing a recent HHS Office of Inspector General report that found one-third of GIP claims inappropriate.

The OIG’s latest semiannual report to Congress also highlights the GIP findings. And Inspector General Daniel Levinson points out that the agency “recommended that the Centers for Medicare & Medicaid Services … increase its oversight of hospice claims and review Part D payments for drugs for hospice beneficiaries.”

“GIP is the second-most expensive level of hospice care and is intended to be short-term inpatient care for symptom management and pain control that cannot be handled in other settings,” the OIG stresses in the report to Congress. “Our findings make clear the need to address the misuse of GIP and hold hospices accountable when they bill inappropriately or provide poor quality care.”

Watch out: CMS agreed with the OIG’s suggestion to implement prepayment review for lengthy GIP stays, the OIG notes in the report.

GIP Frequent Subject Of Whistleblower Suits

A number of hospices have also faced multimillion-dollar settlements of GIP-related charges in recent years. For example, last June Pensacola, Fla.-based Covenant Hospice Inc. agreed to pay the government $10.1 million for alleged overbilling of GIP care in 2009 and 2010 (see Eli’s Hospice Insider, Vol. 8, No. 8). In Covenant’s case, it self-reported its lack of documentation to support GIP. But often the settlements come about because an employee files a qui tam lawsuit, which the government picks up.

Follow this expert advice to avoid a similarly painful payout due to improper GIP billing and documentation:

1. Know what GIP is. Go back to basics to educate yourself on the General Inpatient care service level and what qualifies patients for it. “GIP care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings,” noted HHH Medicare Administrative Contractor National Government Services in a 2012 training session on hospice documentation.

GIP “is initiated when other efforts to manage are ineffective,” notes the National Hospice and Palliative Care Organization in a compliance tip sheet about the service level.

And GIP “is intended to be short-term,” stress attorneys Sara Lord and Elizabeth Mulkey of Arnall Golden Gregory in analysis of the OIG’s GIP report.

Bottom line: “GIP is the level of care for patients who cannot comfortably remain in a residential setting and require skilled nursing care around the clock to maintain comfort,” NHPCO explains.

A prime reason the feds and whistleblowers are so intent on the service is its cost. “GIP is the second-most expensive, and the second-most commonly utilized, type of hospice care,” Lord and Mulkey note. The Medicare daily rate for RHC is $151, while the daily rate for GIP is $672, they say.

2. Know what GIP is not. For a patient to qualify for GIP, your documentation must show that the family or caregivers can no longer provide care, NGS noted. But caregiver breakdown will not support the GIP level of care. “Caregiver breakdown is the loss of the individual’s support structure and should not be confused with the coverage requirements for medically reasonable and necessary care for pain and symptom management that cannot be managed in any other setting,” the MAC instructed.

GIP is not intended for caregiver respite, NHPCO says. It is also not intended as a way to address unsafe living conditions in the patient’s home.

And GIP is not “an ‘automatic’ level of care when a patient is imminently dying,” NHPCO emphasizes. “There must be pain or symptom management and skilled nursing needs present (intensity of care).”

GIP care cannot be provided in the home, an assisted living facility, a hospice residential facility, or in a nursing facility that does not have a registered nurse available 24 hours per day to provide direct patient care, NHPCO says.

GIP is not supposed to last very long, experts stress. Long GIP stays will be a red flag to reviewers and are likely to undergo harsh examination going forward.

3. Document the GIP trigger. “We expect greater emphasis on who decides if GIP is appropriate and greater scrutiny of the decision,” Lord and Mulkey predict.

You should be ready to defend your GIP care with thorough documentation of the decision-making process and content. You need to document the precipitating event — onset of uncontrolled symptoms or pain — that prompted the need to change to GIP, NHPCO advises. (See story, cover page, for a list of pain and symptom items to document). And you should document the pain and symptom management interventions you tried in the home prior to initiating GIP.

The entire interdisciplinary group, including the attending physician and/or the hospice medical director, should assess that the patient requires a higher level of skilled nursing care to achieve effective symptom management, NHPCO recommends. And your documentation needs to show that occurred.

In its report, the OIG recommended to CMS that it should require a physician order for GIP. In its comments on the report, CMS rejected the idea as potentially causing delays to needed care, but pledged to work with the hospice industry on increasing physician involvement.

Best bet: “Industry best practice … states that hospice providers are obtaining a physician’s order to change the level of care,” NHPCO urges.

4. Keep up the documentation. Your patients’ GIP stays should not be very long, but they still need to be well documented. You should document the same types of pain and symptoms that are ongoing to justify the continued service level.

Remember: “If a clinical record is requested by an RHHI/MAC medical review department and it is determined that the patient was not eligible for part of the GIP stay, those days will be downgraded to routine home care days and the corresponding payment rate will apply,” NHPCO warns.

Avoid pitfalls: Vague documentation isn’t going to cut it, especially for this level of care, experts warn. Your documentation must be detailed and specific (see example, p. 60).

Your documentation also must come from all the IDG members, NHPCO advises.

5. Plan for discharge. As soon as you admit a patient to GIP, you should be planning for her discharge, NHPCO urges. “Documentation should show that the IDG is assessing the situation on a daily basis and planning for the transfer to another setting or level of care.”

And “the hospice (not the hospital discharge planners when the facility is a hospital) is responsible for managing the discharge,” the trade group reminds.

One week: The OIG urged CMS in its report to conduct prepayment reviews of GIP stays exceeding seven days. CMS agreed to the concept of more GIP review in general. Providers should “continually review the level of care needed for individual patients, especially for GIP stays approaching the one-week mark,” Lord and Mulkey recommend in their analysis.

6. Step up for visit provision. Transferring a patient to GIP doesn’t let you off the hook for care intensity. “While the frequency of IDG visits to a patient receiving GIP level of care is not specified in the regulations, a good standard of care is daily visits from an IDG member,” NHPCO suggests. That should “assure professional management, coordination of the plan of care, communication with the patient and family, continuity of care and evaluation of continued eligibility for this level of care.” Visits from social workers, chaplains, etc. should continue, the trade group adds.

7. Review GIP billing. Complete a pre-bill audit of GIP claims to review them for correct Q codes and documentation to support the GIP level of care for all days billed at that level, NHPCO says.

8. Start today. Reviewers may still be in the early stages of ramping up GIP scrutiny. Protect your GIP dollars now by self-auditing current claims to prepare for increased scrutiny coming soon, Lord and Mulkey urge.

Note: Get lots more GIP documentation pointers and resources in the NHPCO tip sheet at www.nhpco.org/sites/default/files/public/regulatory/GIP_Tip_GIP_Sheet.pdf. For a free link to and copy of NGS’s training slides, email editor Rebecca Johnson at rebeccaj@eliresearch.com with “NGS GIP slides” in the subject line.