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Feds Crack Down On GIP Level Of Care

Published on Sun Jun 17, 2012

MAC denies majority of claims with 7 or more general inpatient days.

Scrutiny of hospice General Inpatient care days is on the rise. Will your GIP claims pass muster?

The feds are turning up the heat on GIP billing this year. The HHS Office of Inspector General included the topic in its 2012 work plan. "We will review hospice medical records to address concerns that this level of hospice care is being misused," the OIG pledged in the plan.

And Department of Justice officials have announced a string of GIP-related fraud settlements. Last December, Hospice Home Care Inc. in Arkansas agreed to pay $2.7 million for allegedly billing for General Inpatient (GIP) care when the patients received only routine care. And in February, the owner of Good Samaritan Hospice USA Inc. in Muscle Shoals, Ala., pled guilty to Medicare fraud for submitting claims for GIP care when GSH actually provided routine home care. Jackie Randolph Gist received a prison sentence of 28 months and was ordered to forfeit nearly $3.2 million to the government.

At the National Association for Home Care & Hospice's annual March on Washington meeting last spring, Latesha Walker with the Centers for Medicare & Medicaid Services told attendees that reviewers are targeting claims with long lengths of stay for GIP care. Claims for patients with long GIP stays who have diagnoses like dementia, failure to thrive, and debility often fail to have adequate documentation to support the level of care, Walker said.

In a recent edit of claims that contained 7 or more GIP days in a monthly billing period, HHH Medicare Administrative Contractor CGS denied 61 percent, the MAC revealed in its March newsletter to providers. Many of the denials were partial, "where at least some of the GIP days were reduced to the routine rate," CGS explained.

What it is: "General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings," CMS explains in its Medicare Benefit Policy Manual.

Medicare covers GIP "for short periods of time to establish a plan of care to effectively treat the symptoms," CGS explains in its newsletter. "It should be clear in the documentation the patient is in a crisis state, where interventions that could be provided in the home setting, under routine care, would not be adequate, or have not been adequate to control the patient's symptoms."

And when Medicare says short, it means short. "After it has been established that the interventions are working, and the plan of care is effective, the patient's care should again be billed at the routine rate," CGS instructs. "Additional days will not be paid at the GIP level of care for discharge planning."

Data Mining Adds Fuel To GIP Scrutiny Fire

Hospices are seeing more GIP claims reviewed, confirms Holly Swiger with Weatherbee Resources Inc. in Hyannis, Mass. GIP stays average four to seven days, Swiger estimates. It's rare that a hospice can't bring a patient's symptoms under control in that amount of time.

Many hospices make the mistake of keeping patients on GIP too long, observes Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "The GIP level of care for hospice is a limited benefit that is intended to address issues that cannot be addressed in the patient's home setting," Adams says. "Generally the GIP stays are very short -- once the patient's symptoms have stabilized, the patient is returned to routine level of care."

As the hospice industry -- and corresponding Medicare expenditures for hospice services -- have grown at a fast pace, so has scrutiny of hospice claims. And now sophisticated data mining is making it relatively easy for authorities to find and investigate suspected occurrences of upcoding to GIP care, Swiger points out.

For example: In June, Phoenix-based Hospice Family Care Inc. agreed to pay $3.7 million to resolve allegations that it "submitted claims for payment to Medicare for patients who were either completely or partially hospice ineligible or were provided a higher level of hospice care than was necessary or allowable," according to a release from Arizona U.S. Attorney Ann Birmingham Scheel. And former Hospice Family Care owners Nancy Smith and Nancy Turner agreed to be excluded from Medicare, Medicaid, and all other federal health care programs for seven years.

"Our agents used sophisticated data analysis techniques to investigate Hospice Family Care's activities," Glenn Ferry, Special Agent in Charge of the OIG region covering Arizona, says in the release. "Health providers planning to submit false claims to government programs are warned that investigators will be using these data mining tools alongside traditional techniques to root out fraud."

These data red flags can bring investigators to your doorstep for perceived GIP abuse, Swiger warns:
  • Higher GIP billing than your peers'. You may be sticking out like a sore thumb to medical reviewers, investigators, and others based on how many GIP days you bill. CMS contracted with SafeGuard Services, which is also a PSC and ZPIC, to issue a Comparative Billing Report on hospice billing in January 2011. The report covered 2009 claims.»
  • Hospital discharges. Reviewers are on the look-out for cases where a hospital patient under a DRG was discharged directly to GIP. The hospital, of course, will be eager to unload the patient and keep as much of the DRG payment as possible. But the patient may not actually qualify for GIP care, Swiger cautions.
  • SNF residents. Reviewers may be skeptical of GIP care furnished in an institution such as a skilled nursing facility. Medicare doesn't want hospices paying SNFs more to provide the same level of care as under routine home care, Swiger notes. The record must support GIP by showing things like increased time for care, either by SNF or hospice staff.

But aberrant billing patterns don't necessarily add up to provider fraud. One day after the feds announced the settlement in the Hospice Family Care case, Smith and Turner closed on a deal to sell the hospice to an undisclosed buyer, reports the Phoenix Business Journal. "Believe me, if my clients weren't in the process of selling this company, we would have fought this to the bitter end," the company's attorney, Frederick Petti, told the newspaper. "We would have prevailed. This is a business decision."

Even the SGS billing reports admitted that high GIP stats don't equal fraud. "A statistically significant difference from your peers may be an indication of improper usage," the report told hospices.

Don't overlook: Hospices also shouldn't err too far on the side of caution, Swiger admonishes. Billing no GIP days is also not good. You have to make sure you're doing your job for the patient with the resources available, she urges.

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