Eighty-two percent of hospice claims for beneficiaries in nursing facilities in 2006 did not meet at least one Medicare coverage requirement, according to the Office of Inspector General (OIG). In 2006, Medicare paid approximately $1.8 billion for these claims. Eighty-one percent of the claims did not meet at least one Medicare coverage requirement relating to election statements, plans of care, services or certifications of terminal illness, and an additional one percent of the claims were undocumented (i.e., the hospices did not submit any records to support the claims, as required).
Election statements. Terminally-ill individuals who are entitled to Medicare Part A may elect hospice care by filing election statements. For hospice services to be covered by Medicare, election statements must meet certain federal regulations. The regulations aim to ensure that beneficiaries understand the services they will be receiving and foregoing as a result of the hospice benefit. Informed consent for hospice election is particularly important given that beneficiaries may be foregoing life-saving therapies.
Thirty-three percent of hospice claims did not meet election requirements. There were no election statements for four percent of the hospice claims. For another 29 percent of the claims, the election statements did not comply with one or more regulations. In most instances, the election statements did not explain that hospice care was palliative, rather than curative, or explain that the beneficiaries waived Medicare coverage of certain services related to their terminal illnesses.
Plan of care. A plan of care must be established pursuant to federal regulations for each hospice beneficiary in order for hospice services to be covered by Medicare. The plan of care ensures that the individuals involved in hospice care know precisely what is supposed to be done, by whom, at what time, and for what purpose.
Sixty-three percent of the claims did not meet plan of care requirements. The hospices did not establish plans of care for beneficiaries in one percent of the claims. For another 62 percent of the claims, the plans did not meet at least one federal requirement. These plans of care were not established by interdisciplinary groups; did not include necessary components, such as detailed descriptions of scope and frequency of services; or did not specify intervals for review, as required.
Certification of terminal illness. For hospice services to be covered by Medicare, a certification that the individual is terminally ill must be completed pursuant to regulations. In four percent of hospice claims, the certifications were missing or did not meet one or more federal requirements. Some deficiencies included: failure to specify that the individual's prognosis was for a life expectancy of six months or less if the terminal illness ran its normal course; absence of supporting clinical information or other documentation in the medical record; or absence of physician signatures.
Recommendations. The OIG recommended that CMS: (1) educate hospices about coverage requirements and their importance in ensuring quality of care; (2) provide tools and guidance to hospices to help them meet the coverage requirements; and (3) strengthen its monitoring practices regarding hospice claims. CMS concurred with all of the recommendations.
Source: OIG Report, No. OEI-02-06-00221, Sept. 8, 2009.
Visit our News Library to read more news stories.
