01-013 Hospice Portfolio 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 billed on dates of service from January 1, 2018 through December 31, 2018. Below are the review results:

Project ID Project Title Error Rate
01-013 Hospice Portfolio 38%

Background

The Office of Inspector General (OIG) under report OEI-02-16-00570, Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio, dated July 2018, found that hospices frequently bill Medicare for a higher level of care than the beneficiary needs. Hospices inappropriately billed General Inpatient Care (GIP) stays when the beneficiary did not have uncontrolled pain or unmanaged symptoms. The report also identified certain hospices that engage in practices or have characteristics that raise concerns. These concerns include hospices that target beneficiaries in the Assisted Living Facility (ALF) setting, those with a high percentage of beneficiaries with diagnoses that require less complicated care and those that do not provide all levels of hospice care.

The Centers for Medicare and Medicaid Services (CMS) instructed Noridian Healthcare Solutions, LLC (Noridian) as the current SMRC, to conduct data analysis and related medical review activities on GIP hospice claims in the Skilled Nursing Facility (SNF) setting to ensure the services rendered were paid appropriately. The selection of claims for this review was determined by the SMRC through data analysis.

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 ensure the services were paid appropriately in the SNF setting

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.” Addtionally, 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.
  • No Documentation to Support Services as Billed
    • Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6) requires suppliers/providers to provide sufficient information to support that the basic conditions were met for Medicare payment.
  • Initial Certification Not Signed by Physician(s)
    • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20; SSA Title XVIII, Section 1814(a)(7)(A); and CFR Title 42, Sections 418.20 and 418.22 outline the requirements for hospice admission, specifically the certification and election requirements.
  • Missing or Invalid Physician Narrative on Certification of Terminal Illness (CTI)
    • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20; SSA Title XVIII, Section 1814(a)(7)(A); and CFR Title 42, Sections 418.20 and 418.22 outline the requirements for hospice admission, specifically the certification and election requirements.

References/Resources

  • Social Security Act (SSA), Title XVIII, §1812(a)(4), (a)(5), (d)(1). Scope of Benefits
  • SSA, Title XVIII, 1814(a)(7). Conditions of and Limitations on Payment for Services – Requirement of Requests and Certifications
  • SSA, Title XVIII, §1815(a), (e)(2)(D). Payment to Providers of Services
  • SSA, Title XVIII, 1833(e). Payment of Benefits
  • SSA, Title XVIII, 1861(dd). Definitions of Services, Institutions, Etc. – Hospice Care
  • SSA, Title XVIII, 1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §1879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • 42 C.F.R. 418, Subpart A. General Provisions and Definitions
  • 42 C.F.R. 418, Subpart B. Eligibility, Election and Duration of Benefits
  • 42 C.F.R. 418, Subpart F. Covered Services
  • 42 C.F.R. 418, Subpart G. Payment for Hospice Care
  • 42 C.F.R.424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information
  • CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 60. Certification and Recertification by Physicians for Hospice Care
  • CMS IOM, Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 60. Hospice Defined
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10. Requirements—General
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20. Certification and Election Requirements
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40. Benefit Coverage
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 50. Limitation on Liability for Certain Hospice Coverage Details
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 11. Processing Hospice Claims
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Local Coverage Determination (LCD) L33393: Hospice – Determining Terminal Status. Effective October 1, 2015
  • LCD L34538: Hospice Determining Terminal Status. Effective October 1, 2015
  • LCD L34544: Hospice – Liver Disease. Effective October 1, 2015
  • LCD L34547: Hospice – Neurological Conditions. Effective October 1, 2015
  • LCD L34548: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • LCD L34558: Hospice The Adult Failure to Thrive Syndrome. Effective October 1, 2015
  • LCD L34559: Hospice – Renal Care. Effective October 1, 2015
  • LCD L34566: Hospice – HIV Disease. Effective October 1, 2015
  • LCD L34567: Hospice Alzheimer’s Disease & Related Disorders. Effective October 1, 2015
  • Local Coverage Article A52830 Hospice: Determining Terminal Status – Supplemental Instructions Article. Effective October 1, 2015
  • Local Coverage Article A53054 Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • Local Coverage Article A53056 Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions. Effective October 1, 2015
  • MLN Matters SE1628: Documentation Requirements for the Hospice Physician Certification/Recertification

Last Updated Mar 12, 2021