01-009 General Inpatient Hospice Findings of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare General Inpatient Hospice claims billed on dates of service from January 1, 2017 through December 31, 2017. Below are the review results:

Project ID Project Title Error Rate
01-009 General Inpatient Hospice 36%

Background

The Office of Inspector General (OIG), under report OEI-02-10-00491: Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care, dated March 2016, found that hospices commonly billed for General Inpatient Care (GIP) when the beneficiary did not have uncontrolled pain or unmanaged symptoms. According to the report, Hospices inappropriately billed Medicare over $250 million for the GIP level of care.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to conduct medical review. The SMRC performed review activities on GIP hospice claims to determine if the services were paid appropriately.

Common Reasons for Denial

  • Medical Necessity
    • The Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a) provides the guidance that, “no payment may be made under part A or part B for any expenses incurred for items or services which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Additionally, CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual Chapter 9, Section 40 states, “A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings.” The documentation submitted did not support that the level of care was medically reasonable and necessary.
  • No Response to the Documentation Request
    • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
  • Certification of Terminal Illness Signature
    • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual Chapter 9, Section 20.1 states, “For the first 90-day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual’s attending physician if the individual has an attending physician.” The documentation did not support valid signatures on the certification.

References/Resources

  • Social Security Act (SSA) Title XVIII, Sections 1812(a)(4), (a)(5), (d)(1). Scope of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1814(a)(7). Conditions of and Limitations on Payment for Services – Requirement of Requests and Certifications.
  • Social Security Act (SSA) Title XVIII, Sections 1815(a), (e)(2)(D). Payment to Providers of Services.
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1861(dd). Definitions of Services, Institutions, Etc. – Hospice Care.
  • Social Security Act (SSA) Title XVIII, Section 1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer.
  • Social Security Act (SSA) Title XVIII, Sections 1879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
  • Code of Federal Regulations Title 42, Section 424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information.
  • Code of Federal Regulations Title 42, Section 418, Subpart A. General Provisions and Definitions.
  • Code of Federal Regulations Title 42, Section 418, Subpart B. Eligibility, Election and Duration of Benefits.
  • Code of Federal Regulations Title 42, Section 418, Subpart F. Covered Services.
  • Code of Federal Regulations Title 42, Section 418, Subpart G. Payment for Hospice Care.
  • Medicare General Information, Eligibility and Entitlement Manual, Pub. No. 100-01, Chapter 4, Section 60. Certification and Recertification by Physicians for Hospice Care.
  • Medicare General Information, Eligibility and Entitlement Manual, Pub. No. 100-01, Chapter 5, Section 60. Hospice Defined.
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 10. Requirements—General.
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 20. Certification and Election Requirements.
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 40. Benefit Coverage.
  • Medicare Claims Processing Manual (MCPM), Pub. No. 100-04, Chapter 11. Processing Hospice Claims.
  • Medicare Claims Processing Manual (MCPM), Pub. No. 100-04, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN).
  • Medicare Program Integrity Manual (MPIM), Pub. No. 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.

Last Updated Jan 26, 2021