Eli's Hospice Insider

Make sure your documentation supports your claims.

Hospices are getting hit with scrutiny on all sides, as different Medicare contractors train their sights on different types of services.

Supplemental Medical Review Contractor Strategic Health Solutions lists “Y3P0440 — Hospice” as a current topic as of March 15. The HHS Office of Inspector General “issued a report in March 2016 saying a claims analysis found one-third of payments for General Inpatient Care in 2012 were improper, costing Medicare $268 million,” Strategic notes on its website.

“In response to the report, the [Centers for Medicare & Medicaid Services] agreed to determine an appropriate number of claims to review for GIP stays that may be billed inappropriately under Medicare coverage requirements.”

CMS has directed Strategic “to conduct post-payment review of claims for calendar year 2015 to identify claims for GIP care that may have been improperly paid under the Medicare Part A benefit,” the SMRC says. Strategic will be requesting documentation for GIP claims, including records supporting “a precipitating event … such as pain control or acute or chronic symptom management that cannot reasonably be provided in other settings”; “interventions tried … prior to GIP admission were unsuccessful”; pain and symptom control; and Plans of Care “covering the entire GIP stay … including the beneficiary’s response and collaboration with physician services, nursing services, medical social services, and counseling.”

And HHH Medicare Administrative Contractor Palmetto GBA has announced a probe audit of hospice claims with Routine Home Care services. It doesn’t matter whether the services are furnished at home, in an ALF, nursing home, or SNF — they will trigger the audit.

“This probe is based on data analysis that included identified CERT errors, internal analysis and prioritization, as well as past experience, which identified Routine Home Care Hospice Services as a major risk,” Palmetto says. “Probe edits will be set and will select a sample of 100 claims from each edit.”

Among the many items Palmetto lists as required in responding to an ADR for this probe is “for dates of service that include the third benefit period or later … the face-to-face encounter document.” If reviewers find “significant billing aberrancies,” provider-specific medical review and/or one-on-one education may follow, Palmetto warns.

Note: See the SMRC project description and a link to a sample ADR letter at https://strategichs.com/smrc/project-y3p0440-hospice.