Behind OIG’s National Audit of Hospice GIP

Hospices need to have solid documentation to demonstrate a patient’s need for general inpatient care (GIP) as regulatory oversight zeroes in on those services.

GIP can involve longer stays and higher costs. For these reasons, the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG) is launching a new audit that will focus on GIP.

The OIG’s “Audit of Selected, High-Risk Medicare Hospice General Inpatient Services” will examine Medicare claims for hospice enrollees who were transferred to general inpatient care (GIP) following an acute hospitalization.

Hospices have increasingly come under a regulatory microscope around GIP in particular during the past few years, according to Jessica Gustafson, founder and attorney of The Health Law Partners LLP. The OIG’s audit signals that oversight could be tightening up, she stated.

“I have seen increasing GIP hospice audits in recent years. The OIG’s announcement is a good indication that hospices can expect auditing in this area,” Gustafson told Hospice News in an email. “It is reasonable for hospices to expect that long length GIP stays will be under scrutiny.”

GIP risks in regulators’ sights

Hospice providers are reporting spikes in auditing activity related to general inpatient care, particularly those from Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE) conducted by Medicare Administrators Contractors (MACs), according to Erin Burns, senior associate in hospice and palliative care at Husch Blackwell.

Both types of audits focus on identifying recurrent errors on Medicare claims or billing practices that the the U.S. Centers for Medicare & Medicaid Services (CMS) considers unusual.

“TPE and SMRC audits are currently the two kinds related to GIP services that hospices are actively getting more of,” Burns told Hospice News. “We’re also seeing a lot of claim denials related to physician visits during GIP services. So I think this is an area where a lot of hospices are getting tripped up around, both in terms of qualifying patients for GIP services and with physician visits.”

These audits are designed to instill regulatory safeguards against bad actors in the hospice industry, though they can come with challenges for any provider, Burns indicated. Regulators generally treat documentation and billing errors as red flags.

“Most GIP patients need a higher level of care, so it’s reasonable that they’re getting physician services that are medically necessary and those are billable,” Burns said. “But we often run into physicians without good documentation skills, and that makes it hard for them to demonstrate that GIP should be paid separately.”

Regulators become particularly concerned when GIP patient stays exceed one to two weeks, as well as the associated claims, Burns indicated.

Balancing GIP compliance

Rising regulatory scrutiny may be impacting how some hospices approach inpatient care delivery, Gustafson indicated.

“Hospices acting in good faith should be in a strong position to succeed during an audit if their care plans reflect that GIP services are required for pain control or symptom management,” she said. “However, I have had hospice clients that have chosen not to bill at the GIP level of care for the entirety of a GIP stay when they had concerns that the duration of GIP services could not be supported from Medicare’s point of view.”

A leading issue for hospices is that they are required and encouraged to offer GIP care, but they do so under watchful eyes, Gustafson said.

CMS in its recently proposed 2024 hospice payment rule included a series of requests for information (RFIs) that included questions about patient utilization of high-cost, complex care. This included questions related to general inpatient settings.

“To support a GIP level of care, it is important that the plan of care support that the beneficiary requires a change in the level of care (i.e., increased care) for pain control or symptom management,” Gustafson stated.

Keys to GIP compliance include solid documentation practices and staffing training, Burns said.

Administrative staff should have a firm grip on how to ensure billing claims are in line with regulatory requirements, while clinicians need the education and training in how to identify and document a need for this level of care, she explained.

“What we tell our hospice clients is that one thing regulators may always harp on is documentation,” Burns said. “So it’s vital to make sure that you’re clinicians understand what’s required to be on this higher level of care and its standards. It’s easier to have that solid documentation of proof upfront than to try and bolster it on the back end by appealing these audits.”