Series: Review of Hospices' Compliance with Medicare Requirements

Servicios Suplementarios de Salud, Inc. (the Hospice), located in Puerto Rico, claimed Medicare reimbursement for some hospice services that did not comply with certain Medicare requirements. Of the 100 beneficiary-months in our random sample for which the Hospice claimed Medicare reimbursement, 82 beneficiary-months complied with Medicare requirements, but 18 did not.

The Community Hospice, Inc. (the Hospice), operating in New York State, claimed Medicare reimbursement for some hospice services that did not comply with certain Medicare requirements. Of the 100 beneficiary-months in our random sample for which the Hospice claimed Medicare reimbursement, 93 beneficiary-months complied with Medicare requirements, but 7 did not. We estimated that the Hospice received at least $447,000 in improper Medicare reimbursement.

Hospice of New York, LLC (the Hospice), operating in New York State, claimed Medicare reimbursement for some hospice services that did not comply with certain Medicare requirements. Of the 100 beneficiary-months in our random sample for which the Hospice claimed Medicare reimbursement, 79 beneficiary-months complied with Medicare requirements, but 21 did not. We estimated that the Hospice received at least $1.3 million in improper Medicare reimbursement.

Tullahoma did not comply with Medicare requirements for 35 of the 100 claims in our sample. For these claims, Tullahoma claimed Medicare reimbursement for hospice services (1) for which the clinical record did not support the beneficiary's terminal prognosis, (2) that were not documented, and (3) for which the notice of election was not filed timely with the Medicare Administrative Contractor.

These improper payments occurred because Tullahoma's policies and procedures for ensuring that claims for hospice services met Medicare requirements were not always effective. On the basis of our sample results, we estimated that Tullahoma received at least $3.4 million in Medicare reimbursement for hospice services that did not comply with Medicare requirements.

Suncoast did not comply with Medicare requirements for 49 of the 100 claims in our sample. For these claims, Suncoast claimed Medicare reimbursement for hospice services for which the clinical record did not support the beneficiary's terminal prognosis or the level of care claimed and for services that were not provided.

These improper payments occurred because Suncoast's policies and procedures for ensuring that claims for hospice services met Medicare requirements were not always effective. On the basis of our sample results, we estimated that Suncoast received at least $47.4 million in Medicare reimbursement for hospice services that did not comply with Medicare requirements.

Tidewell did not comply with Medicare requirements for 18 of the 100 claims in our sample. For these claims, Tidewell claimed Medicare reimbursement for hospice services for which the clinical record did not support the beneficiary's terminal illness prognosis or the level of care claimed and for services that were not eligible for Medicare reimbursement.

These improper payments occurred because Tidewell's policies and procedures for ensuring that claims for hospice services met Medicare requirements were not always effective. On the basis of our sample results, we estimated that Tidewell received at least $8.3 million in Medicare reimbursement for hospice services that did not comply with Medicare requirements.

HPBC received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 60 claims complied with Medicare requirement. However, the remaining 40 did not comply with the requirements. Specifically, the clinical record did not support the beneficiary's terminal illness prognosis (30 claims), the clinical record did not support the level of care claimed (9 claims), and services were not supported in the medical record (3 claims). The total exceeds 40 because 2 claims contained more than 1 deficiency.

Improper payment of these claims occurred because HPBC's policies and procedures were not effective in ensuring the clinical documentation it maintained supported the terminal illness prognosis, the appropriate level of care was provided, and that services were supported. On the basis of our sample results, we estimated that HPBC received at least $42.3 million in improper Medicare reimbursement for hospice services.

Alive received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 76 claims complied with Medicare requirements. However, the remaining 24 claims did not comply with the requirements. Specifically, for 16 claims, the clinical record did not support the beneficiary's terminal prognosis, and for the remaining 8 claims, the clinical record did not support the level of care claimed for Medicare reimbursement.

Improper payment of these claims occurred because Alive's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis and that the appropriate level of care was provided. On the basis of our sample results, we estimated that Alive received at least $7.3 million in unallowable Medicare reimbursement for hospice services.

Ambercare received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 48 claims complied with Medicare requirements. However, for the remaining 52 claims, the clinical record did not support the beneficiary's terminal prognosis.

Improper payment of these claims occurred because Ambercare's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis. On the basis of our sample results, we estimated that Ambercare received at least $24.6 million in unallowable Medicare reimbursement for hospice services.

Franciscan received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 79 claims complied with Medicare requirements. However, the remaining 21 claims did not comply with the requirements. Specifically, for 19 claims, the clinical record did not support the beneficiary's terminal prognosis, and for the remaining 2 claims, there was no documentation to support the hospice services that Franciscan billed to Medicare.

Improper payment of these claims occurred because Franciscan's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis and the hospice services billed to Medicare. On the basis of our sample results, we estimated that Franciscan received at least $13 million in unallowable Medicare reimbursement for hospice services.

NW Hospice received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 81 claims complied with Medicare requirements. However, for the remaining 19 claims, the clinical record did not support the beneficiary's terminal prognosis. Improper payment of these claims occurred because NW Hospice's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis. On the basis of our sample results, we estimated that NW Hospice received at least $3.9 million in unallowable Medicare reimbursement for hospice services.

Mission received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 66 claims complied with Medicare requirements. However, the remaining 34 claims did not comply with the requirements. Specifically, for 33 claims, the clinical record did not support the beneficiary's terminal prognosis, and for 1 claim, the clinical record did not support the level of care billed to Medicare. In addition, for a few claims, there was no evidence that beneficiaries elected hospice care before the periods covered by the sampled claims, or there was no support for physician services billed to Medicare.

Improper payment of these claims occurred because Mission's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis, election statements were signed before the periods covered by the sampled claims, the appropriate level of care was billed, and physician services were supported. On the basis of our sample results, we estimated that Mission received at least $10.5 million in unallowable Medicare reimbursement for hospice services.

Partners received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 53 claims complied with Medicare requirements. However, the remaining 47 claims did not comply with the requirements. Specifically, for 43 claims the clinical record did not support the beneficiary's terminal prognosis, and for the remaining 4 claims, the clinical record did not support the level of care claimed for Medicare reimbursement.

Improper payment of these claims occurred because Partners' policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis and that the appropriate level of care was provided. On the basis of our sample results, we estimated that Partners received at least $11.2 million in unallowable Medicare reimbursement for hospice services.

Vitas did not comply with Medicare requirements for 89 of the 100 claims in our sample. Specifically, the clinical record did not support the continuous home care (CHC) level of hospice care claimed for Medicare reimbursement (68 claims), the clinical record did not support the general inpatient level of hospice care claimed for Medicare reimbursement (28 claims), and CHC services were not documented or supported in the beneficiary's clinical record (23 claims). The total exceeds 89 because 27 claims contained more than 1 error.

These improper payments occurred because Vitas' policies and procedures were not effective to ensure that it maintained documentation to support the level of care and hospice services claimed for Medicare reimbursement. On the basis of our sample results, we estimated that Vitas received at least $140 million in improper Medicare reimbursement for hospice services that did not comply with Medicare requirements.