The U.S. Centers for Medicare & Medicaid Services (CMS) is conducting a small pilot program for post-payment reviews of hospice stays that exceed 90 days.
The agency has contracted with Noridian Healthcare Solutions, LLC as its Supplemental Medical Review Contractor (SMRC). Noridian will perform the reviews and submit findings to CMS.
“CMS internal data has identified a potential area of vulnerability beginning with the second benefit period, or 91st day in hospice,” Noridian indicated in an announcement. “The SMRC was tasked to perform data analysis and conduct medical record review activities.”
Noridian will review Part A hospice claims that were filed during the calendar year 2021. The SMRC will notify hospices under review with a statement of reasons, request for documentation as well as informational resources.
In 2022, the projected improper payment amount for hospice care is expected to be close to $2.9 billion, a rate of 12%, Noridian indicated.
The review process is the most recent step that CMS has taken to strengthen hospice oversight in recent months. Others include a 36-month rule that limits when a hospice can be sold, publication of hospice ownership data and associated requests for information from providers.
The agency is also developing “enhanced oversight” for providers in California, Nevada, Arizona and Texas, which reportedly have become hotbeds of fraud and abuse.
The upcoming SMRC reviews will examine 10 items and types of documents, Noridian indicated:
- Hospice Election Statement and Hospice Election Statement Addendum:
- Hospice Certification of Terminal Illness (Initial and subsequent to cover billed dates of service), from Certifying Physician and Attending Physician (if applicable) including written and oral/verbal certification (if applicable) and Physician’s narrative
- Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered, include a dose, route, and frequency given
- Physician Order for Hospice
- Hospice initial and comprehensive assessment, and updated assessments covering all specified dates of service
- Interdisciplinary Team/Group (IDG/IDT) meeting notes with full list of participants and clear distinction of professional disciplines
- Documentation that supports the beneficiary’s need for the level and frequency of home health or hospice services provided, including any changes during the period under review
- Advance Beneficiary Notice of Non-Coverage (ABN)/ Notice of Medicare Non-Coverage (NOMNC)
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
- Any other supporting documentation