Medicare Compliance & Reimbursement

19 percent of these claims didn't meet the 5-day rule, OIG finds If you provide respite care for your hospice patients, keep your eye on the calendar -- the HHS Office of Inspector General (OIG) investigated and found that 19 percent of these claims are being billed inappropriately. To make sure you follow the lead of the on-the-level providers, take a few notes from the OIG's recent report. Respite care is short-term care, providing "respite" for the patient's family or others who care for the patient at home. But according to the March 31 OIG report, "Hospice Beneficiaries' Use of Respite Care," CMS
was concerned about Medicare payments for respite care while patients were actually residing in nursing homes, according to the report results by Inspector General Daniel R. Levinson. During its review of the 17,669 respite care claims that were billed to Medicare in 2005, the OIG investigated whether CMS made inappropriate payments that didn't meet the respite care criteria. For instance, CMS will not reimburse respite care services that occurred more than five consecutive days at a time. The outcome: The OIG found that 81 percent of respite care beneficiaries stayed within the five-day limit during the review period. On the other hand, the report also noted, "on average, beneficiaries received respite care for 5.6 days in 2005." This left some healthcare consultants scratching their heads about how the majority of patients stayed within the five-day period. "People are wondering if this was a typo," says Randall Karpf of East Billing in East Hartford, CT. "But keep in mind that Medicare's rule only says that respite care reimbursement is limited to five consecutive days, so several stays during the same one-year period may be payable if Medicare deems them as such." In fact, the report notes, the number of days in respite care during the review period ranged from one to 122. So even if 81 percent of patients spent less than five days in respite care during 2005, the patients on the higher side would balance that average out to more than five days.