Hospice has become one of the areas targeted for investigations by the Office of Inspector (OIG) and the Department of Justice (DOJ) in their common goal to reduce the vulnerabilities of the Medicare and Medicaid programs, including reducing improper payments and holding wrongdoers accountable, HHS Inspector General Daniel Levinson told attendees of the Health Care Compliance Association (HCCA) 20th Annual Compliance Institute. In light of the government’s focus on hospice services, a HCCA breakout session addressed the top five hospice risk areas and provided details of what compliance officers need to know and what they need to do.
The risk areas presenters Laura E. Ellis, Senior Counsel, HHS-OIG, Office of Counsel to the Inspector General (OCIG); Jason E. Christ, Member, and Serra I. Schlanger, Senior Associate, of Epstein Becker Green; and Lynn Strange, Chief Compliance Officer, Nathan Adelson Hospice identified, include: (1) eligibility and appropriateness, (2) financial arrangements with referral sources and medical directors, (3) the level of care, (4) documentation, and (5) governance and effective oversight. Other risks noted were problems with admitting a patient at the wrong time, families not being aware that the beneficiary is in hospice care, ensuring that marketing incentives do not include patients exceeding six months on an average length of stay, and risks specific to profit or nonprofit organizations.
Why focus on hospice? Risks and recommendations
The presenters noted that in 2013, Medicare expenditures for hospice services totaled about $15.1 billion which was more than a 40 percent increase in spending since 2000. Of that amount, nearly $9 billion was spent on patients with lengths of stay exceeding 180 days. From 2000 through 2012, the length of stay at the 90th percentile increased from 141 days to 246 days.
Eligibility and appropriateness of hospice benefits. Among the specific areas that the presenters identified that the government will be looking at in terms of eligibility, include whether the patient’s diagnosis and prognosis meet the eligibility requirements for admission, re-admission, and long lengths of stay; whether the hospice failed to discharge clinically ineligible patients; and the hospice’s live discharge rates. Presenters stressed that eligibility for admission or readmission must be supported in medical records, including the patient’s condition and prognosis. The presenters recommended that hospice providers audit and monitor high risk areas, evaluate data to identify trends and outliers, and review PEPPER reports and hospice CAP overpayment trends. The presenters also suggested that compliance officer look at reports on a monthly basis.
Financial arrangements and marketing practices. Financial arrangements include kickbacks to referral sources, swapping arrangements, arrangements with medical directors, and incentives tied to admissions and census goals. To mitigate risks in financial arrangements, the presenters suggested focusing training for marketing staff on interactions with referral sources and beneficiaries, contracting review for financial arrangements with referral sources, and evaluating internal compensation and incentives. Specifically, the presenters told listeners to look at relationships with other facilities, the qualifications of medical directors, and whether the hospice pays bonuses to the right people at the right time. Further, compliance officers should develop a good relationship with and provide for training for sales and marketing staff.
Levels and location of care. Presenters identified appropriateness of hospice general inpatient (GIP) care, use of continuous crisis care services, and services provided to beneficiaries in assisted living facilities (ALFs) and skilled nursing facilities (SNFs) as risk areas for hospices to keep on their radar. Auditing and monitoring higher levels of care, evaluating data to identify trends, investigating outliers, and increasing oversight of ALF and SNF patients will mitigate these risks, presenters said. They also recommended involving physicians in decisions regarding care.
Documentation. CMS will be looking at the adequacy of physician attestations, clinical documentation, financial records and any other documents that support claims for payment, the presenters noted. To ensure compliance, systems should be implemented to ensure timely certifications and face to face evaluation. In addition, hospice providers should operationalize documentation practices and provide documentation training for its staff member.
Governance and effective oversight. Risk areas at the Board level include failures to: (1) set compliance direction at the top, (2) take action early due to a lack of knowledge, and (3) allocate sufficient resources. To mitigate risks to the hospice, presenters stressed that compliance officers meet with the Board regularly in executive session; develop a compliance dashboard for the Board; encourage questions and discussions, including feeding questions to the Board if none are asked to start the ball rolling; and involve executive leadership in risk identification and remediation. Lynn Strange, added that conducting an “external audit brings credibility to the Board.”