The HHS Office of Inspector General report on the use and misuse of hospice inpatient care in the Medicare Hospice Benefit, that was released on March 31, 2016, was undertaken as part of an ongoing effort at OIG to prevent inappropriate claims for hospice general inpatient care (GIP), including care being billed but not provided and beneficiaries receiving care they do not need.
As the oldest and largest leadership organization representing hospice and palliative care providers and professionals, the National Hospice and Palliative Care Organization continues to welcome appropriate oversight of the field and works continually with its members to ensure their awareness of and compliance with all hospice related rules and regulations.
NHPCO has also worked closely with Congress and CMS to promote policy changes that stem the abuses referenced in the report, and ensure a high quality hospice experience for consumers. The following policy changes – many of which were implemented after the 2012 study period – are already in place to ensure appropriate payment for hospice services:
1. Part D Prior Authorization: In July, 2014, CMS issued revised interim guidance to ensure correct payment for prescription drugs covered under part D and hospice, and to guard against “double billing” for certain drugs. Specifically, beneficiaries must seek prior authorization to receive coverage for prescription drugs that are used for the most commonly treated conditions at end of life – pain, nausea, constipation and anxiety. These modifications will go a long way to reducing ‘double billing’ in part D.
2. Program Integrity: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 included a provision requiring more frequent surveys for hospice organizations. Effective April 6, 2015, Medicare certified hospices will have mandatory surveys every 36 months, through 2025.
3. Payment Reform: In January 1, 2016, CMS introduced a revised payment system for hospices. The reformed system pays a higher rate for the first 60 days of rate for routine home care that reflects the higher costs hospices face upon a patient’s election. Thereafter, the daily rate is lower. It also offers a service-intensity add-on for skilled nursing or social worker visits in the final seven days of life. While the new payment methodology does not modify the General Inpatient rate, it ensures a payment methodology that reflects hospices costs. It is worth noting that, overall, General Inpatient costs account for only 6 percent of overall hospice costs. The inappropriate charges referenced in the OIG report account for less than 2 percent.
4. Face to Face: Beginning January 1, 2011 face-to-face encounters are required for patients entering their third benefit period and each subsequent period of 60 days. This additional layer of scrutiny will ensure appropriate care planning, as recommended by OIG.
Further, NHPCO is also working with member hospices to ensure appropriate use of GIP. Specifically, NHPCO recommends that hospices:
- Have a process and procedure for determining eligibility for the GIP level of care, that they document the reasons that GIP is appropriate for each patient, and evaluate continued eligibility for GIP EVERY DAY with documentation in the medical record that can be easily reviewed.
- Obtain a written physician order for a change in level of care.
- Review use of GIP and the length of stay for each patient at the GIP level of care on a monthly basis, with documentation about the review in each patient’s medical record.
- Review the development of plans of care for patients admitted to and continuing in the GIP level of care.
- Develop a process for reviewing all medications, check and double check how medications are paid for and ensure that contract providers are billing appropriately.
- Review and update your processes at inpatient facilities to ensure daily evaluation of eligibility, detailed documentation to prove continued eligibility and accurate and complete care plans.
NHPCO will continue to work with member organizations, policymakers, and other stakeholders to ensure that hospice claims are billed appropriately, and that beneficiaries experience high quality, compassionate care at the end-of-life.
Sharon Scribner Pearce in Vice President of Public Policy at the National Hospice and Palliative Care Organization and works closely with advocacy efforts of the affiliated organization Hospice Action Network.