Hospices inappropriately billed Medicare $268 million for inpatient care that is only supposed to be given to patients with uncontrolled pain or symptoms that can't be managed at home, according to a new report by HHS' Office of Inspector General.
The OIG found that hospices billed one-third of general inpatient care stays inappropriately in 2012, based on data from a medical record review of a random sample of all such stays during that year. In those cases, beneficiaries either did not need the care at all, didn't need it for part of the time they got it or there was no evidence that the beneficiary had chosen hospice care or had a terminal illness.
Such general inpatient care is intended to serve those who need short-term symptom management and pain control that can't be handled at home. It's the second most expensive level of hospice care. To be eligible for any hospice care a patient must have a terminal illness with a life expectancy of six months or less.
“The findings in this report make clear the need to address the misuse of (general inpatient care) and hold hospices accountable when they bill inappropriately or provide poor quality care,” according to the report.
The report detailed examples of patients with a circulatory disease who could have been cared for at home but instead cost more than $31,000 in hospice care.
Joe Rotella, chief medical officer for the American Academy of Hospice and Palliative Medicine, said the report shows hospice medical directors still need to be trained. He said it's possible some hospices just aren't properly documenting the medical need for such care, meaning the problem may not be as large as the report suggests.
He said the academy, which serves physicians, nurses and others specializing in hospice and palliative medicine, is committed to helping educate medical directors on who should be given inpatient care and how to document it.
He said, however, that he hopes the report doesn't have a chilling effect on providing inpatient hospice care.
Industry group National Hospice and Palliative Care Organization has been educating its members for some time about general inpatient care, said Jon Keyserling, senior vice president for health policy and counsel with the organization.
Keyserling said the qualifications of the contractors who reviewed medical charts for OIG's study isn't clear, but the organization doesn't dispute the thrust of OIG's findings.
“Any overbilling or any inappropriate billing is absolutely unacceptable,” Keyserling said. “We knew that some providers had misunderstandings about this level of care, and we have suggested in the past that the CMS target those providers who have extraordinarily long lengths of stay or high levels of (general inpatient care) usage.”
The organization is recommending hospices make sure they have processes for determining eligibility for inpatient care, document the reasons such care is appropriate and evaluate continued eligibility for such care every day with documentation, among other things.
The report found that some states, such as Florida, had especially large numbers of inappropriate billings. For-profit hospices were more likely than others to inappropriately bill, the report found.
Medicare sometimes paid twice for drugs because they were paid for under Part D when they should have been covered under the hospice daily payment rate, according to the report.
The report included a number of recommendations for the CMS, including that it increase its oversight of inpatient claims; ensure a physician is involved in the decision to use inpatient care; conduct pre-payment reviews for long inpatient stays; increase surveyor efforts to ensure hospices meet care planning requirements; and come up with more enforcement remedies for poor hospice performance, among other things.
In its formal response to the report, the CMS agreed with the recommendations, though it noted that Medicare payments for general inpatient care account for only 1.5% of Medicare hospice expenditures.
The CMS noted that though it agrees a physician should be involved in the decision to use inpatient care, it worries that doing so could cause delays in patient care. The agency said it would work with the hospice community on other options to expand physician involvement. The CMS will revise its basic hospice training for surveyors.
The agency is working to develop a strategy that targets improper payments without increasing documentation burdens for providers.