The Office of the Inspector General’s (OIG) Work Plan provides hospice facilities a blueprint for their compliance activities for the following year. For 2018, the OIG has hinted that it will put special scrutiny on transports and Medicare and Medicaid claims next year.
All Transports Should Be ‘Medically Necessary’
Hospice has always fallen under the steely gaze of Medicare auditors, but some industry watchers have found that transports to and from hospices and other facilities are receiving special scrutiny.
“When you transport a Medicare beneficiary, you should always bill Medicare, right? Wrong! There are times when the bill should instead go to the patient, a group health plan, hospice, a hospital or a skilled nursing facility (SNF).”” noted one legal team. “The key to compliance and proper billing is evaluating the transport and determining which payer is responsible.”
Their advice? Have a process in place for identifying the proper payer for each transport. “Any time you receive payment from Medicare when you shouldn’t have, such as when another payer should have been billed, it is an overpayment that must be refunded. To avoid overpayments, or worse, accusations of submitting false claims, you must have a process in place for identifying the proper payer for each transport.”
Watch Out for Unallowable Hospice Claims
The OIG’s Work Plan is now updated monthly. Additions made in October included reviews related to drugs, and, in July, to Medicare and Medicaid payment claims, particularly Medicare payments for unallowable hospice claims.
According to an OIG announcement, this update means that “a hospice beneficiary waives all rights to Medicare payments for any services that are related to the treatment of the terminal condition for which hospice care was elected or treatment of a related condition or treatment that is equivalent to hospice care. Excepted are those services provided by another hospice under arrangement or by an independent attending physician.”
The announcement adds that in previous OIG audits and inspections this noncompliance with Medicare billing requirements popped up.
In the original 2017 Work Plan, released in November 2016, hospice featured prominently as well:
- Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement: A Portfolio
- Review of Hospices’ Compliance with Medicare Requirements
- Hospice Home Care – Frequency of Nurse On-Site Visits to Assess Quality of Care and Services
OIG Backlog Hints at Areas Attracting Heat
Other goals previously identified by the OIG are sitting on the agency’s list of unimplemented recommendations. The two items on the agency’s “top 25” list are hospice-related actually made the top 5. Coming in at number 3 is “Medicare should adopt a hospital transfer payment policy to lower hospital reimbursement for beneficiaries who are discharged early to hospice care.” This stems from a 2013 report that “estimated that Medicare could have saved $602.5 million for calendar years 2009 and 2010 by applying a hospital transfer payment policy for early discharges to hospice care.”
And coming in at number 5, OIG had also recommended that the Centers for Medicare & Medicaid Services “reform hospice payments to reduce the incentive for hospices to target beneficiaries with certain diagnoses and those likely to have long stays”—and that this recommendation had been made the year previous. The report adds that while CMS did update its payment structure in 2016, “OIG does not consider the new payment structure to be the best way to align payments with patient needs because it does not address the vulnerability of hospices targeting beneficiaries to achieve the greatest financial gains.”
The recommendation comes from an OIG report in 2015 which raised concerns “about the financial incentives created by the current payment system and the potential for hospices to target beneficiaries in ALFs because they may offer the hospices the greatest financial gain. Together, the findings in this and previous OIG reports show that payment reform and more accountability are needed to reduce incentives for hospices to focus solely on certain types of diagnoses or settings.”
The recommendation? That CMS reform payments to reduce incentives, target some hospices for review, develop and adopt claims-based quality measures, make hospice data publicly available and educate hospices about how they compare to their competition.
Identify Your Hospice’s Risk Areas, Then Strengthen Compliance
With the 2018 Work Plan due to be released any day now, C-suite execs, administrators, compliance officers and clinical leadership will want to hear what Susan Balfour has to say. Balfour’s conference for ProfEdOnDemand, “What’s Ahead for Hospices? Getting Ready for 2018,” will equip hospice administrators who want to learn how to use a risk assessment prioritization tool to assess internal and external functions, then create a customized plan of action. The session provides an analysis of the OIG Work Plan as it relates to hospices for 2018, next steps with the Hospice Quality Reporting Program, how to conduct an agency-specific risk assessment and update you on Medicare Part D and hospice.
