The U.S. Department of Health & Human Services Office of the Inspector General (OIG) is planning a nationwide audit of hospice eligibility. The audit will focus on patients who did not have a hospitalization or emergency department visit prior to electing hospice.
OIG has planned the audit for calendar year 2023 and will contact individual hospices to request Medicare claims and associated documentation. The impetus for the 2023 audit comes from the results of previous, less extensive inquiries.
“Beneficiary eligibility has always been a concern for hospice,” an OIG spokesperson, identified as a “subject matter expert,” told Hospice News. “Additionally, in the last couple of years, our agency has done numerous individual hospice audits, and every one of them found issues with beneficiary eligibility.”
The question of hospice eligibility is one of the most frequently targeted issues in regulatory enforcement. Hospice organizations are under increasing legal and regulatory scrutiny related to medical necessity complaints under the False Claims Act and the closely related anti-kickback statute.
A Feb. 2021 report from Bass, Barry, and Sims shows that a leading cause of fraud involves hospices billing Medicare for services for which patients were not eligible. This resulted in several multi-million dollar settlements during 2020, with amounts ranging from $1 million to $5.25 million.
A few of these cases have reached as high as the U.S. Supreme Court. While the high court to date has not agreed to hear any of those cases, earlier this week the justices asked the U.S. Solicitor General to weigh in on litigation involving Bethany Hospice.
Since the pandemic began in early 2020, many patients have shunned or delayed institutional care due to fears of acquiring COVID-19 or losing access to family members due to safety restrictions. This could mean that larger numbers of patients could fall into the category that OIG is examining. Many hospices have reported that their referral mix has shifted during the pandemic, with more coming from physician offices and fewer from hospitals.
“We are aware that hospices, even without a pandemic in progress, will receive referrals from physician offices,” the OIG spokesperson said. “However, we believe that this group of hospice beneficiaries may be an eligibility area that [the U.S. Centers for Medicare & Medicaid (CMS)]should consider.”
While OIG routinely examines compliance throughout the health care sector, the impact of their reports can be substantial. Two OIG reports in 2019 shook many in the hospice community and received widespread media coverage. The first OIG report indicated that about 20% of hospices surveyed by regulators or accreditors between 2012 and 2016 had a condition-level deficiency that posed a serious safety risk.
A second report discussed 12 examples of those deficiencies in-depth. OIG examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016. Regulators and accreditors surveyed nearly all hospice providers in the nation during those years.
These reports ultimately led CMS to overhaul its survey process during 2021, including new provisions for surveyor training and greater transparency for consumers.
“Our goal in doing this work is to help [CMS] identify areas that may be high risk in terms of eligibility and need more oversight,” the OIG spokesperson indicated. “Those hospice beneficiaries without an emergency room visit or inpatient hospital stay could be high risk from an eligibility perspective.”
OIG recently reported to Congress that its audit finding and investigative work has recovered nearly $4 billion in funds allegedly lost to Medicare, Medicaid and other HHS programs. This amount is a total from across the health care spectrum, including but not limited to hospice.
“For 45 years, our agency has been at the forefront of the fight against waste, fraud, and abuse in Medicare, Medicaid, and other HHS programs,” said Christi A. Grimm, OIG’s Principal Deputy Inspector General. “And during these challenging times, our mission to protect the public and taxpayer dollars is more important than ever.”
