Eli's Hospice Insider

Whistleblower suit shows why your non-routine hospice claims must be squeaky clean.

Get ready to dot the I's and cross the T's to withstand growing scrutiny of general inpatient care.

At the heart of a recently unsealed whistleblower lawsuit lie allegations that an Arkansas hospice's GIP claims were unnecessary and the care level not provided (see story, p. 51). That's just one example of how the GIP issue has moved into the hot seat.

Why: Medicare currently pays $622.66 per day for GIP care compared to $140.14 for routine home care, the Centers for Medicare & Medicaid Services said in a Sept. 10, 2008 memo. That big pay increase leads intermediaries and other authorities to want to make sure the difference is legitimate.

The interest is compounded by the fact that GIP utilization has increased in recent years, notes Samira Beckwith with Hope Hospice and Community Services in Ft. Myers, Fla. But that increase is more because GIP was not utilized enough before, not because there is inappropriate use of the care level now, Beckwith maintains. "Just because there's an increase doesn't mean there's something wrong," she insists.

Kickback complication: GIP reimbursement gets even more dicey when the nursing home part of the equation is considered, experts say. Artificially inflating GIP care is "an illegal way to pay nursing homes a lot more money," Beckwith notes.

In the whistleblower lawsuit, relator Arkansas Hospice Inc. of Little Rock accuses competitor Hospice Home Care Inc. of paying nursing homes more than fair market value for room and board for GIP patients. And HHC claimed to referral sources and patients that the nursing home stay was "free" to patients due to the GIP level of billing, the qui tam lawsuit alleges.

Hospices can't provide GIP care for any old reason. The Medicare hospice benefit allows for short spells of GIP care only when it's not feasible to provide the needed services in any other setting, explains consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

"Reasons for general inpatient stay include pain control, management of acute or chronic symptoms, medication adjustment, or treatment stabilization that have not responded in the home or other settings or are [to] such a degree that it requires the higher level of staffing available in the inpatient setting," Adams relates.

For an in-depth look at strategies for risk-proofing use of the GIP benefit, see pages 51 and 53.