Clinton administration proposes amendments
Clinton administration proposes amendments
ORT findings lurk behind concerns
Controversy over government audits of hospices continues to rage in the media and at hospice gatherings, setting the stage in late March for the Clinton Administration to address government concerns about fraud and abuse in hospices and other Medicare providers. (See related story, p. 55.)
The President’s Medicare/Medicaid proposals, which he intends to introduce in Congress, contain a dozen amendments to Medicare statutes, including three to the hospice benefit. A fourth proposal, to eliminate Medicare hospice coverage for beneficiaries residing in nursing homes, was tabled, at least temporarily, following vigorous behind-the-scenes lobbying by the Arlington, VA-based National Hospice Organization (NHO).
In a March 25 memorandum to NHO members, NHO president John J. Mahoney related how a White House representative had contacted the organization prior to release of the administration’s proposal, giving hospices an opportunity to argue on behalf of preserving access to hospice care for nursing home residents. The other three hospice amendments in the Clinton proposal were less controversial, two of them resembling provisions in the NHO-sponsored Medicare Hospice Benefit Improvement Act of 1996, which the organization succeeded in getting re-introduced in this year’s Congress as HR 521.
Provisions in the President’s plan include the following points:
• tying hospice reimbursement to the point of actual service, not the provider’s office location, which means urban hospices would receive lower regionally adjusted rates for providing services in rural areas;
• replacing the unlimited fourth hospice benefit period with an unlimited series of 30-day benefit periods, which would lock hospices into regular reevaluation of long-stay patients’ terminal status;
• expanding waiver-of-liability protections for providers to cover eligibility denials based on prognosis, which means hospices would not be punished financially for occasional incorrect determinations of prognosis.
Fraudulent doctors face monetary penalties
Another provision of the plan would subject physicians who knowingly and fraudulently certify patients’ eligibility for certain Medicare services to civil monetary penalties, although this would not apply to honest mistakes and differences in medical opinion.
The President’s proposed legislation, "The Medicare/Medicaid Anti-waste, Fraud and Abuse Act of 1997," builds on the government’s comprehensive efforts to fight health care fraud. It includes numerous measures to strengthen the provider qualification process, bar participation by felons and the hiring of excluded individuals, ban kickbacks, and close other loopholes. These proposals are designed to work in tandem with other anti-fraud and abuse proposals in the President’s fiscal year 1998 budget.
At press time, the wild card for hospices, still hanging precariously in the balance, was the administration’s intention to eliminate or alter the hospice nursing home benefit by prohibiting Medicare payments to any entity other than the skilled nursing facility for services or supplies furnished to Medicare-covered residents.
Hospice must police itself
NHO’s goal is to find a way to address administration concerns while still preserving the benefit for terminally ill nursing home residents, Mahoney says. However, "the clear message we’re getting is that they’d like to do something about the nursing home benefit; that is their clear agenda," he adds. The White House is afraid that the nursing home benefit is particularly vulnerable to fraudulent behavior, Mahoney says, adding that OIG has verbally reported that it has evidence of specific fraudulent behavior by one or more hospices. Such behavior is said to involve patient records, inducements for referrals, and failure to provide additional hospice services to nursing home residents enrolled in hospice. At press time, NHO’s legislative committee was drafting counterproposals that might satisfy administration concerns about the benefit.
Hospice care in nursing homes was a major ORT target. While no written reports or auditors’ findings in this area have been released, hospice leaders indicate that serious cases of real abuse of the benefit have been alleged, apparently more serious and less open to dispute than OIG’s controversial audits of long-stay hospice patients. (See related story, p. 55.)
"My understanding is that OIG has uncovered some specific problems in the way people provide care in the nursing home," says J. Donald Schumacher, PsyD, CEO of Hospice of Western New York in Cheektowaga and chairman of a newly appointed NHO Task Force on Care in the Nursing Home. A survey conducted last year by NHO suggests that "some hospice programs are trying to provide hospice care in the nursing home that is minimalistic, rather than appropriate. Some of it is that people aren’t sure how to do it and need more education. But there also appears to be some intent to abuse the benefit by some folks," Schumacher explains.
"What we now have to do is to develop some formal process by which we as an industry can police ourselves," he adds. The most reasonable way to separate out genuine concerns about abuses in the nursing home setting is "to make sure the services hospices provide to patients living in the nursing home meet the same standards as the care they provide to hospice patients living in their own homes. If we can ensure that is how business is being done, then we will be in a stronger position," Schumacher says.
NHO’s nursing home task force will address three main thrusts:
• guidelines and standards;
• documentation issues;
• the philosophy behind enrolling nursing home patients in hospice care.
"I’d also like to see a study of what is provided to patients in the nursing home rather than to scrap the entire program and for HCFA to realize that many patients are benefitting from this service," Schumacher says.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.