01-036 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 hospice billed on dates of service from January 1, 2018 through December 31, 2019. Below are the review results:

Project ID Project Title Final Claim Error Rate
01-036 Phase 2 ALF Setting 29%
Hospice Portfolio Phase 3 Hospices That Only Provide Routine Home Care 47%

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. The OIG also found that Medicare beneficiaries receiving hospice services in the Assisted Living Facility (ALF) setting had a higher prevalence of ill-defined diagnoses and an increased length of stay compared with beneficiaries receiving hospice services in other settings. In addition, the OIG found there are hospices that do not provide all levels of care, but instead are billing only for providing Routine Home Care (RHC) for all Medicare beneficiaries they serve.

Reason for Review

In response to the OIG report, CMS instructed Noridian to conduct data analysis and related medical review activities on hospice claims in the ALF setting to address the three areas of OIG concern referenced above for calendar year 2018, collectively known as Phase 2. Concurrently, Noridian also conducted data analysis and related medical review activities for hospices that do not provide all levels of care for calendar year 2019, known as Phase 3.

Common Reasons for Denial

Phase 2

  • No Response to the Documentation Request
    • CMS Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). The documentation was not submitted or not submitted timely.
  • Invalid Face-to-Face
    • CMS Internet-Only Manuals 100-02, Medicare Benefit Policy Manual Chapter 9, 20. Face-to-Face Encounter requirements not met. Requirements include, but are not limited to, the appropriate timeframe of the encounter, attestation requirements, and which practitioners can perform the encounter.
  • Continuous Home Care (CHC) Not Reasonable and Necessary
    • Social Security Act 1861(dd), Code of Federal Regulations (CFR) Title 42, Section 418.302, and CMS Internet-Only Manuals 100-02, Medicare Benefit Policy Manual Chapter 9, 40.2.1.

Phase 3

  • No Response to the Documentation Request
    • CMS Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). The documentation was not submitted or not submitted timely.
  • Invalid Notice of Election/Hospice Election
    • CMS Internet-Only Manuals 100-02, Medicare Benefit Policy Manual Chapter 9, 20, Social Security Act 1812(d)(1). Also refer to 42 CFR, Section 418.24. The hospice election is invalid because it doesn’t meet statutory/regulatory requirements.
  • Certification Not Submitted
    • Social Security Act 1814(a)(7) and Code of Federal Regulations (CFR) Title 42, Sections 418.20, 419,22 and 424.5(a)(6). No certification present in the documentation submitted for the dates billed.

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)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • 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
  • Code of Federal Regulations (C.F.R.) Title 42, §424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information
  • 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
  • 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. Coverage of Hospice Services Under Hospital Insurance
  • 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 3.2.3.2. Timeframes for Submission
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • 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 (LCA) A52830 Hospice: Determining Terminal Status – Supplemental Instructions Article. Effective October 1, 2015
  • LCA A53054. Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • LCA A53056. Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions. Effective October 1, 2015

Last Updated Jan 20, 2022