Hospice providers nationwide are reporting an increase in Medicare Administrative Contractor (MAC) audits pertaining to claims for general inpatient care (GIP) stays that are longer than seven days. These audits can be expensive and time consuming processes for hospices; some of whom say they fear that this practice will inhibit patient access to that level of care.
The U.S. Centers for Medicare & Medicaid Services (CMS) requires hospice providers to offer all four levels of care: routine home care, general inpatient care, inpatient respite care and continuous home care. The agency has no rules that set a limit on GIP length of stay, a CMS spokesperson told Hospice News in an email.
“General inpatient care is allowed when the patient’s medical condition warrants a short-term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings,” CMS indicated in the email. “For a hospice to provide and bill for the general inpatient level of care, the patient must require an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting.”
Hospice utilization among Medicare decedents rose to exceed 50% for the first time during 2018, according to CMS. As utilization climbs, so does the amount of dollars CMS spends on hospice care, spurring the agency and other regulators to step up enforcement in an effort to control costs. Medicare hospice expenditures rise by about $1 billion annually.
Documentation errors and omissions, live discharges and lengths of stay beyond six months are frequent red flags that could cause regulators to come knocking at a hospice’s door.
CMS temporarily suspended Targeted Probe and Education audit activity to reduce the burden on providers during the COVID-19 pandemic. In August 2020, MACs indicated that they would resume some medical review audits related to a limited number of topics. These topics include “review of inpatient claims for inpatient hospice care (GIP) greater than or equal to 7 days for revenue code 656 and for place of service codes Q5004 – Q5009,” according to Judi Lund Person, vice president for regulatory and compliance for the National Hospice and Palliative Care Organization (NHPCO).
Lund Person indicated that scrutiny of GIP utilization has been ongoing for a number of years, dating back to 2013 reports from the U.S. Department of Health & Human Services Office of the Inspector General.
“I would not expect that scrutiny of long stay GIP claims will subside,” Lund Person said. “A hospice must be vigilant with documentation and continuing assessment of whether the patient continues to meet GIP eligibility criteria.”
Complete and accurate documentation is critical to avoiding or navigating these audits. Hospices need to consistently monitor the patient’s condition and document daily, or in some cases multiple times per day, the reasons that the individual’s symptoms could not be managed in the home, according to Lund Person.
CMS told Hospice News that while each MAC will periodically adjust the volume of medical reviews for GIP or other Medicare services based on data analysis and workload, the agency does not believe the number of claims reviewed has increased significantly. Two of the largest MACs, CGS and Palmetto GBA — both subsidiaries of the Celerian Group — did not respond to inquiries from Hospice News.
Nevertheless, providers have said otherwise in discussions with Hospice News and have reported increased GIP audits in communication with national industry associations.
“It’s sad to me, because I feel like we have a great hospice program that’s really vulnerable because of this activity,” said Christy Whitney, CEO of Colorado-based hospice provider HopeWest. “We are losing money hand over fist, partly because we have all this administrative overhead. It’s become almost like a no-win situation to running your hospice program.”
Whitney told Hospice News that the prevalence of these audits are creating a chilling effect for providers. She said that a contingent of hospices have stopped sending patients to inpatient care, often leading to increased revocations of the benefit and higher hospitalizations and readmissions.
The health care data analytics firm HealthPivots recently analyzed claims data from 4,750 separate provider numbers for Medicare-certified hospices for calendar year 2020. Their analysis found that 2,283 of those provider numbers reported no general inpatient care stays that year, about 48%. Generally, these providers have the ability to provide that care, but haven’t, at least during 2020.
Nearly two-thirds of GIP occurs in a dedicated hospice facility, compared to 31% provided in hospitals and 2% in skilled nursing facilities, according to HealthPivots. Hospices that do not operate their own facilities can contract with hospitals or skilled nursing operators to offer GIP in their buildings.
HealthPivots also found that while between 15% and 20% of hospice patients spend some time in GIP, that level of care represents only about 1% of hospice care days. This indicates that while a substantial number of patients receive GIP, length of stay is often very short, according to HealthPivots President Jay Cushman.
“The provision of GIP is driven largely by whether or not programs can organize their own hospice facilities, which are costly, or have contracts with other providers, like hospitals or skilled nursing facilities,” Cushman said. “It’s harder to organize those programs than routine home care.”
Data from NHPCO show that 2020 was not an outlier year due to the pandemic. GIP represented 1.7% of patient care days in 2014 and incrementally dropped to 1.2% by 2018.
In addition the the MACs, Supplemental Medical Review Contractors such as Noridian Healthcare Solutions, conducted post-payment reviews of GIP claims for calendar year 2017, finding that the most common reason for denial was that documentation did not sufficiently support the medical necessity of that that level of care, according to Lund Person.
In some cases, Noridian reportedly did not receive a response to their request for documentation or found that the certification of terminal illness was not valid.
Documentation is the critical piece when it comes to these audits, but other considerations do at times muddy the waters. This includes the inherent complexity and unpredictability of a patient’s illness trajectory, most particularly with non-cancer diagnoses.
Determining a six-month terminal prognosis and selecting an appropriate level of care is often a judgement call rather than an exact science, as is the case in some instances for the auditors evaluating those claims. Some stakeholders have argued that claims denials indicate a difference of opinion between the health care provider and the payor or regulatory body, rather an evidence of malfeasance.
Whitney recounted a HopeWest patient with a broken pelvis who transitioned to general inpatient care after suffering a heart attack. Following the cardiac event, her pain had worsened; she became bedridden and was virtually comatose for about 10 days prior to death. The MAC pulled the patient’s chart for an audit and denied the claim for a billing period that included only the patient’s final day of life. The patient was Whitney’s own mother.
“I think CMS needs to be directed to clarify the criteria for general inpatient care by the Congress, because they have not been willing to do it themselves,” Whitney told Hospice News. “We use the [Medicare Hospice Benefit] as it was designed and, constantly, we have care denied that was provided in good faith and according to all the rules. I think that the auditors are making everything black and white.”