A recent Office of Inspector General (OIG) report titled Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements (Compliance Report), found that hospices failed to meet one or more Medicare coverage requirements in 82% of claims for services provided to nursing facility residents. Specifically, the Compliance Report found, in part, that 63% of the claims did not meet hospice plan-of-care requirements, 33% of the hospice claims did not meet election requirements, and in 4% of the claims the certification was either missing or did not meet one or more certification requirements. This data should be especially alarming to hospices because failing to meet the Medicare coverage requirements jeopardizes a hospice provider’s primary source of revenue.

Even though the Compliance Report was limited to an analysis of claims for hospice services provided to nursing facility residents, there is little reason to believe that the findings would not be consistent if applied to all hospice patients. In fact, recent survey data shows that care planning continues to be among the most frequently cited hospice survey deficiencies. As of August 2009, five of the top ten survey deficiencies nationwide were related to the interdisciplinary group, care planning and coordination of services requirements of the Hospice Conditions of Participation (CoPs), 42 CFR 418.56.

Historically, the CoPs have been enforced through periodic certification surveys. However, as pointed out in the Compliance Report, there is a general lack of regulatory oversight in the hospice industry since certification surveys are only required every six years. To compound this problem, between 2000 to 2005, 86% of hospice agencies were surveyed within six years, while 14% averaged three years past due. This extended survey frequency creates substantial barriers for hospice providers to learn how to effectively care plan patient and family services.

The OIG further acknowledged this general lack of regulatory oversight by stating in its Compliance Report: 

“The extent to which hospices did not meet coverage requirements raises concerns about the services that Medicare is paying for and the quality of care that hospices are providing to beneficiaries during their last months of life. The results of this review also indicate that [the Centers for Medicare & Medicaid Services “CMS”] current oversight procedures are inadequate and that it must do more to ensure that hospices deliver care that meets Medicare requirements. Given the nature of hospices’ noncompliance – which does not appear to be related to the beneficiaries setting – these concerns extend to all Medicare beneficiaries receiving hospice care.” Compliance Report, p. 17.

Among the recommendations made by the OIG in its Compliance Report is that CMS should strengthen its monitoring practices regarding hospice claims. This would include targeted medical reviews and oversight mechanisms to improve hospice performance and compliance, with an emphasis on establishing plans of care and providing services consistent with those plans of care, as well as more frequent certification surveys. CMS responded, in part, that it will provide the information contained in the Compliance Report to the Recovery Audit Contractors (RACs) to determine if this is an area they wish to audit.

Targeted medical review of hospice claims to determine if Medicare coverage requirements have been met creates an urgency for hospice providers to ensure that they comply with all hospice Medicare coverage requirements. This includes not only the technical  requirements of the election and certification regulations, but the more subjective requirements of the interdisciplinary group, care planning and coordination of services standards of the CoPs. For example, you should make sure that (i) all hospice services are provided in accordance with an individualized plan of care established by the interdisciplinary group in collaboration with the attending physician, if any, the patient or representative, and the primary caregiver, if any of them so desire; (ii) the plan of care reflects the patient and family goals based on the problems identified in the initial, comprehensive and updated comprehensive assessments; (iii) the plan of care includes a detailed statement of the scope and frequency of services to meet the specific patient and family needs; (iv) the plan of care is reviewed and revised as frequently as the patient’s condition requires but no less frequently than every 15 days; and (v) the care and services are provided in accordance with the plan of care.

You should start now to ensure that your agency is in compliance with all Medicare coverage requirements, including plans of care, election statements and certifications of terminal illness. One way to achieve this is to audit your compliance with these requirements as part of your quality assessment and performance improvement program. The coverage requirements will likely be an area for RAC audits, and non-compliance with these requirements, or failure to clearly document your compliance with the requirements, may result in recoupment of Medicare payments made for noncovered hospice services. Given the alarming percentage of hospice claims that failed to meet Medicare coverage requirements, including care planning, it is apparent that a number of hospices will need to revisit these requirements, train their staff accordingly and ensure that they carefully document the care provided.