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Plans of care and payments targeted
The U.S. Office of Inspector General (OIG) intends to scrutinize hospice plans of care, payments to nursing homes, and use of continuous home care, drawing some concern from the National Hospice and Palliative Care Organization (NHPCO) but no cries of unfair scrutiny.
"We’re not sure, but we don’t think there should be any cause for concern," says Angela Thimis, spokeswoman for the Alexandria, VA-based NHPCO.
The OIG issued its Work Plan for Fiscal Year 2001 in October, outlining areas in which the department intends to focus its fraud and abuse investigations. The 103-page document covers all segments of health care. The hospice section, which was just more than a page long, represented a fraction of the OIG’s plan.
The Work Plan provides valuable guidance for identifying high-risk compliance areas. Providers and suppliers should review and address relevant Work Plan projects in their ongoing internal compliance efforts.
The three areas of the hospice industry to be scrutinized by the OIG are:
• Plans of Care.
It seems the OIG is concerned with variances between the plans of care and the actual care provided to patients, despite the fact that similar investigations in nursing homes showed that services were generally provided in accordance with the plans of care.
"This study will examine the variance among hospice plans of care and the extent to which services are provided to hospice patients in accordance with the plans of care," the OIG Work Plan states. "Although hospice patients are required to have plans of care, there are no requirements or minimum standards that the plans must meet. In previous OIG work on nursing home populations, we found that plans of care varied and that services were generally provided in accordance with the plans of care."
The OIG offered a hint in 1999 that this area would be one on which it would focus when its Compliance Program Guidance for Hospices, issued on Sept. 30, 1999, identified it as a potential risk area.
The NHPCO’s only concern is how the OIG will determine appropriate care and substandard care, says Thimis. Because hospice care is so individualized, two patients who have the same terminal diagnosis can have very distinct care plans.
• Payments to Nursing Homes.
Hospice payments to nursing homes have been the subject of OIG scrutiny for many years and have been addressed in OIG fraud alerts, reports, and the Hospice Compliance Program Guidance. Prior studies found that payment levels for patients in nursing facilities may be excessive. The OIG will evaluate the financial implications of Medicare hospice payments made on behalf of beneficiaries residing in nursing facilities.
"Our previous work found that current payment levels for patients in nursing facilities may be excessive," the Work Plan states. "Otherwise, we feel this is a reasonable area for the OIG to study."
According to the OIG, when a patient is entitled to both Medicare and Medicaid, the nursing home no longer bills the state Medicaid program for the patient’s long-term care. Instead, the nursing home bills and receives payment from the hospice, and the hospice is reimbursed by Medicaid. Medicaid payments for room and board are in addition to Medicare’s daily fixed rate paid to the hospice. Private-pay patients continue to pay the nursing facility directly, while Medicare pays the hospice.
• Continuous Home Care.
An OIG study will review how fiscal intermediaries ensure that hospices provided the services for which they submitted claims. Hospices are reimbursed based on four levels of care, three of which are fixed at a per diem rate. However, payment for the continuous home care level is based on the number of hours of care, with a minimum of eight hours on a particular day. The OIG will review this level of service because of its complexity, expense, and vulnerability to misuse.
Because of the potential for claims denial, few hospices offer this service, says Thimis. "We’re finding too little use of continuous home care," she adds. The NHPCO is hopeful that OIG will provide clarification and guidance so hospices can provide this service and be confident that they will be reimbursed for it.