Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules.
Audits are becoming more frequent in the hospice space, and GIP is an increasing focus, including for the most common types — Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE). In a survey earlier this year, more than half of hospice providers reported having undergone multiple types of audits within a six-month period.
“The government is auditing to see that short term inpatient care is provided when the patient’s medical condition warrants it, because there is an acute or something that’s going on with that patient that feasible, cannot feasibly be managed or provided in other settings,” Rachel Hold-Weiss, partner at the law firm of Benesch, Friedlander, Aronoff, LLP, said during a presentation at the National Hospice and Palliative Care Organization (NHPCO) Annual Leadership Conference.
In addition to these routine MAC audits, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) has been performing a national audit of GIP utilization, as well as an additional investigation into management of the associated payment cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20% of a hospice’s total Medicare patient care days, according to OIG. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.
Hospices and other stakeholders have developed a variety of methods, tools and resources for complying with GIP requirements. Among them, three key themes stand out.
Understanding the requirements
To comply with regulations, providers must first understand them, including the criteria for escalating a patient to the general inpatient level of care.
GIP is used for acute symptom management that cannot be addressed in the home or other setting, according to Hold-Weiss. Operators may not provide that level of care in a home, hospice residential facility, assisted living or a long term care nursing home, she said.
For GIP, the hospice must provide 24-hour nursing care, as well as clear collaboration between the hospice staff and the facility, each of which has a separate set of responsibilities. The hospice, for instance, must retain primary management of the patient.
Circumstances that seem severe do not necessarily necessitate use of GIP, such as when a patient is actively dying, when caregivers need respite, when unsafe conditions exist in the home or simply because a patient is currently located in a hospital.
“Just because the patient is in the hospital doesn’t mean they are in need of GIP level of care if they’re coming off a regular hospital stay. It has to be something that is going on with that patient that can’t be provided somewhere else,” Hold-Weiss said. “It’s really patient dependent, not facility dependent. It’s what is going on with the patient that day that requires that patient to be on GIP care.”
Effective documentation
The importance of complete and accurate documentation cannot be overstated. Errors and omissions in clinical documentation are the leading cause of audit and survey deficiencies, as well as claims denials when it comes to GIP.
The documentation must demonstrate and justify each day that the patient continues to need general inpatient care. It must identify any precipitating events and circumstances, changes in patient’s condition, updates to the care plan, as well as visit and documentation frequency. All members of the interdisciplinary team must document to “paint a complete picture of the patient,” Hold-Weiss indicated. This includes any symptoms that clinicians can’t effectively manage outside of GIP.
Documentation must provide clear, specific reasons the patient needs GIP, address symptoms, interventions, education and discharge planning, and should use consistent language and terminology, Kim Skehan, vice president of accreditation for Community Health Accreditation Partner (CHAP), said during the NHPCO conference.
Common errors include missing signatures, mistakes or omissions in the hospice election statement, lacking documentation of a face-to-face encounter and missing or insufficient physician narratives, according to Hold-Weiss.
“You have to meet all of these small technical elements on the election statement, and it’s very easy to miss a checkbox. In many cases, what we are seeing is not that the patient wasn’t eligible for hospice services, but the documentation did not support GIP,” she said.
Be prepared
Hospices would be well-served to be continuously ready for an audit or survey by accreditors or the U.S. Centers for Medicare & Medicaid Services (CMS), Skehan indicated. This includes some best practices.
For starters, organizations should have an annual audit plan and a compliance effectiveness and risk assessment to ensure they are keeping track of all relevant requirements, anticipating and correcting potential problems and to maintain readiness for when regulators darken their doors.
Providers should also make sure that their entire staff understands their corporate compliance plan and their roles and responsibilities when it comes to both regulatory compliance and in responding to an audit or review of GIP utilization, according to Skehan. Staff should receive education about federal and state hospice regulations, including Conditions of Participation and Conditions of Payment.
Another important strategy is to conduct mock surveys annually using current CMS survey protocols, Skehan said. Operators also need to have methods of holding staff accountable for compliance.
“Ensure review and observation to ensure staff knowledge and implementation of policies and procedures, and just remember that the focus is primarily on patient care documentation, both in audit and in survey,” Skehan said. “A strong concurrent review process, staff education and supervisory visits to the facilities and for patients in GIP are key areas for holding staff and management accountable to the regulations. Documentation and audit compliance, as well as survey readiness, should be an ongoing agency-wide effort.”
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Benesch Friendlander Aronoff, Community Health Accreditation Partner (CHAP)