Hospice Improperly Claimed $447K in Medicare Reimbursement
- The office of inspector general (OIG) of the Department of Health and Human Services released the results of a study of Medicare reimbursement claims by The Community Hospice, Inc. The organization operates in New York State. According to the study, Community improperly claimed at least $447,000 in Medicare reimbursement during 2010.
Through the Medicare hospice benefit, providers are able to claim Medicare reimbursement for hospice services that are provided to individuals with a life expectancy of six months or less and have opted for hospice care. In similar studies of other providers, a high percentage of hospice claims were found to not meet certain Medicare requirements.
There are Federal regulations in place for beneficiaries to be eligible for Medicare hospice benefits. Namely, a beneficiary must be entitled to Medicare Part A and being certified as having a terminal illness with a life expectancy of six month or less if the disease runs its normal course. A beneficiary can leave the Medicare hospice service at any time, as inclusion is voluntary.
Reimbursement for these services is available at one of four predetermined rates that are based on the level of care provided for each day that a beneficiary is under the hospice’s care.
The report covered 9,147 beneficiary-months during which Community received Medicare reimbursement totaling $28,396,090 for hospice services provided during the calendar year of 2010. A beneficiary-month includes all hospice services provided to a beneficiary during a single month. A random selection of 100 beneficiary-month were chosen and all medicare payments for hospice services were reviewed. It was discovered that 93 of these months complied with Medicare requirements while seven did not.
The improper payments of those seven months occurred for one of two reasons. The first is that Community did not alway maintain adequate documentation to support a beneficiary’s eligibility for hospice service. The second is that Community did not always ensure it was billing Medicare for the appropriate level of hospice care. This led the hospice service to receive $447,469 in Medical reimbursement for services that did not comply with certain Medicare requirements.
As a result, CMS recommended Community refund the full sum to the federal government and take steps to strengthen its procedures to ensure that it complies with Medicare requirements for claiming hospice services.
Commenting on the report and the recommendations, Community agreed to improve its processes. However, it did dispute the financial disallowance. Specifically, Community agreed to refund Medicare payments associated with four of the seven months but claims to have “ample documentation to support the beneficiary’s terminal prognosis in the three remaining samples.” The company also contests the extrapolation of the audit results to arrive at an estimated repayment amount. These comments did not change the stance of the OIG.
