OIG Will Continue to Audit/Monitor Improper Medicare Payments

Overview: A Breakdown of the OIG’s 2022 Workplan

This Whitepaper will take a deep dive with auditing expert La Tanya McNair into the OIG’s 2022 Workplan. It will examine hospice benefits, recertification requirements, documentation requirements, hospice services, facility notifications (also known as NOEs), and billing modifiers.

The OIG (Office of Inspector General) 2022 Workplan

In the OIG’s Annual Workplan for the fiscal year 2022, we see that the OIG will continue to audit and monitor potentially improper payments to non-hospice providers for items and services provided to Medicare beneficiaries outside the Medicare hospice benefit during the time the beneficiary was in hospice care. For example, if providers bill Medicare for non-hospice item services that potentially should be covered by hospice, Medicare could pay for the same item or service twice. In this scenario, it would be considered unbundling since the items and services would have already been paid under the hospice per diem. Please be advised that CMS policy, effective October 1, 2022, states it will hold hospices accountable to properly inform the beneficiaries through transparency. This means that hospice agencies must properly document and inform beneficiaries which services are covered during hospice and which services are considered outside of the hospice benefit for services that are unrelated to the patient’s terminal illness. When we talk about an audit performed by CMS over a 10-year audit period, say from 2010 to 2019, CMS analysis has dictated an upward spike in improper Medicare payments of 6.6 billion to non-hospice providers over ten years for items and services provided to hospice beneficiaries which suggest the need for increased oversight according to the OIG’s data brief report in February 2022.

Hospice Benefits

To be eligible for Medicare hospice benefits, the beneficiary must be entitled to Medicare Part A and be certified as having a terminal illness with a life expectancy of six months or less if the illness runs its normal course. When a beneficiary elects hospice, the hospice agency assumes responsibility for medical care related to the beneficiary’s terminal illness and related conditions for the hospice period of care. Under hospice care, the beneficiary weighs Medicare coverage for services related to the curative treatment of a patient’s illness. For example, if a beneficiary were receiving radiation therapy and or chemotherapy treatments prior to hospice for treatment of brain and or breast cancer, this beneficiary would terminate such elective treatment and elect hospice care that provides palliative rather than curative care.

One of the big misconceptions of hospice care is that a patient under hospice care does not receive medical treatment beyond palliative care. This is not true. If a hospice patient has a urinary catheter in place and incidentally develops a urinary tract infection, the hospice provider would order the labs, order medications accordingly, and treat the patient’s infection. In this scenario, the laboratory and pharmacy would invoice the hospice agency for reimbursement since the hospice agency ordered the services. To avoid unbundling issues, the hospice agency must effectively communicate with the laboratory and the pharmacy.

Benefit Periods

Hospice care is given in benefit periods. A hospice patient can receive hospice care for two 90-day benefit periods followed by an unlimited number of 60-day benefit periods. However, recertification is required for each benefit period. A benefit period starts the day the beneficiary signs onto hospice care and ends when the beneficiary’s 90-day or 60-day benefit period ends. A valid physician’s certification or recertification is required for each benefit period that the beneficiary is on Medicare for hospice benefits. A hospice patient can revoke hospice care at any time. For example, suppose a hospice patient feels they want to give curative treatment another chance, or subsequently, the patient feels their illness is getting better. In that case, they can revoke hospice care without the consent of their physician. Patients in home-hospice often have family members as primary caregivers. A family member of a hospice patient in need of rest or a break in care, i.e., respite care (short-term care provided in an approved in-care patient facility as a relief to the primary caregiver) can be arranged for just an afternoon or several days. Medicare will cover most of the cost up to five consecutive days per period for respite care in a hospital or skilled nursing facility for a patient receiving hospice care. Payments for respite care can be made for a maximum of five consecutive days, including the day of the admission but not counting the day of discharge. It is helpful to think of how many days the patient had their head on the pillow at night at the facility when calculating the number of respite days. The hospice agency will coordinate respite care and transportation efforts.

Hospice Recertification Requirements

Hospice recertification requirements vary by state, and it is highly recommended that you check your state’s policy for specific requirements. For example, Nevada has one of the most robust recertification requirements. For many states, at the start of each patient’s benefit period, the hospice medical director or hospice doctor must re-certify that the patient is terminally ill. Additionally, Nevada requires an annual independent face-to-face review to re-certify a patient for hospice if the patient has been on hospice for 12 months. The independent review must be completed no sooner than 30 days before the end of the patient’s 12-month certification period. The twelve-month independent face-to-face review can be conducted by an MD, a DO, a PA, or an MP. This independent face-to-face review is subsequently required every twelve months after that if the Medicaid beneficiary continues to receive extended hospice care. The extended care form for Medicaid, an FA-96 form, must be submitted along with the prior authorization request and additional supporting documentation to Nevada Medicaid for approval for hospice reimbursement. Many facilities on a state level and Medicaid have similar reimbursement criteria that must be met to authorize a patient for hospice. Please note that prior authorization request forms are state-specific, and you should check with your individual state Medicaid policy for their specific forms. It is imperative to submit recertification documents in a timely manner. If not, the recertification on file will expire or lapse, and Nevada Medicaid will not reimburse the hospice agency for services if their authorization has expired or lapsed. This means that the recertification authorization will default back to the original recertification date that the documents are submitted and approved, thus creating a revenue deficit for the hospice agency if not submitted and approved in a timely manner. Nevada Medicaid recertification documents include but are not limited to the hospice program election notification form, the certification of terminal illness (known as the CTI), the hospice prior authorization request form, the face-to-face visit, and assigned at a station, hospice plan of care, the hospice election of benefits (EOB consent form). Patients who are initially certified for hospice would require a history and physical. For patients who are past their 12 months on hospice, there would be a hospice extended care review form that needs to be submitted.

Documentation Requirements

Documentation requirements mentioned in the chart level should include but are not limited to the patient’s terminal diagnosis. Common terminal diagnoses for hospice patients may include at least one of the following: cancer, cardiovascular disease, dementia, pulmonary disease, stroke, or chronic kidney disease. Secondary conditions related to the terminal diagnosis should also be documented, such as hypertension, cardiac disease, or diabetes with renal disease. Documentation is also needed of co-morbidities unrelated to the terminal diagnosis. For example, a patient with COPD who may also suffer from depression, diabetes, or high blood pressure.

A patient's BMI should also be documented, as BMI as a decreased BMI could indicate poor appetite, loss of weight, or failure to thrive. Weights are duly taken and recorded on hospice patients.

For patients who cannot stand or ambulate, chair weights and Hoyer lift weights are ordered and utilized. Additionally, routine measurements and documentation of a mid- arm circumference (MAC), is an essential measure of a patient’s nutritional status. A nutritional assessment and descriptions of that nutritional assessment could be the patient’s visual appearance — maybe the patient looks emaciated, thin, normal, overweight, or obese. Documentation also needs to include competencies concerning activities of daily living. For example, whether the patient is independent, requires the use of a device, requires a personal assistant, or is completely dependent on activities such as ambulation, continence, transfers, and feedings, bathing, or dressing.

Heart Association’s Functional Classification Documentation

Documentation includes the Heart Association functional classification, a four-class grading system used to classify the extent of disease for a patient with heart disease. Documentation elements for the New York Heart Association functional classification include physical activity limitations. How much and which activities are limited? For example, the patient’s level of discomfort at rest and symptoms caused during physical activities such as fatigue, palpitations, dystonia, or angina pain. How much activity performed causes associated symptoms? For example, symptoms develop with normal activity, less than the ordinary activity, minimal activity, or no activity at all.

Pain and Pain Management Documentation

Documentation of pain and pain management should include but not be limited to a pain scale assessment, applicable orders for pain medication, and applicable orders for a bowel regime; such as the use of a laxative or stool softener.

Pain medications have been known to cause side effects, such as constipation, so documentation of the side effects is crucial. Also, documentation of the use of non- pharmacological therapies such as meditation or massage is necessary. Documentation should include a review of the patient’s treatment plan, a written plan for pain management, and documentation of comfort goals. Often patients have pain diaries where they indicate their pain level.

Patient-Centered Care Planning

All hospice cares and services furnished to patients and their families must follow an individualized patient-centered written care plan established by the interdisciplinary hospice group in collaboration with the attending physician, the patient, the patient’s representative, and the primary caregiver in accordance with the patient needs. The hospice must ensure each patient and the primary caregiver receive education and training as to their responsibilities for the care and services identified by the patient’s plan of care. Instructions to family members should also include proper hospice notification in case of an emergency. Often, hospice providers will leave a book of instructions at the patient’s residence so that the family member is well advised on what to do in case of an emergency and who to call. The plan of care must include, but is not limited to, a review and updates by the interdisciplinary group at intervals specified in the plan of care (but not less frequently than 15 calendar days). The plan of care should continually be assessed to ensure that the care the beneficiary receives meets their conditions and needs. When reviewed, the plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress towards the outcome and goals specified in the plan of care. The patient’s care plan should be updated if the beneficiary’s condition improves or deteriorates. The changes to the level of care will include an assessment of the individual’s needs and identifying the services needed. This includes management of discomfort and relief of symptoms. The plan of care must state in detail the scope and frequency of the services required to meet the beneficiary and family needs. The plan of care should act as a road map for the interdisciplinary group to provide consistent, cohesive care and will support the medical necessity of the patient’s hospice care.

Palliative Performance Scale (PPS)

Hospice providers use the PPS as a tool to measure and document a hospice patient’s functional performance.

The PPS measures five functional domains:

    1. Ambulation: Is the patient mainly in bed or bed-bound? Is the patient’s activity level normal?
    2. Activity and Evidence of Disease: Is the patient able to walk or do any work? Is there evidence of disease or extensive disease?
    3. Self-care: Does the patient need occasional assistance or total care?
    4. Oral Intake: Does the patient have normal oral intake, take minimal sips, or require mouth care?
    5. Level of Consciousness: Is the patient fully conscious, confused, drowsy, or in a coma?

What about the Functional Assessment Staging Scale, also known as FAST? Hospice providers also use FAST as a screening test to quantitatively assess and measure the degree of disability of a hospice patient diagnosed with dementia or Alzheimer’s disease, and to document changes that occur over time. This includes the patient’s decreased ability to perform complex tasks, the patient’s inability to put on clothes properly, the patient’s inability to bathe properly, speech ability, ambulatory ability, or the patient’s loss of ability to smile.

Inconsistent Documentation

As an auditor, it is quite common to find inconsistent documentation within the medical record chart when providers use standard EMR templates to document. It’s too easy just to click and check a box using the template’s standard verbiage or click a box to carry over encounter information from a previous visit that is unrelated to the chief complaint of the current visit. For example, once while auditing a cardiology facility, a provider used the standard EMR template to document. Most of the patients at the facility were being treated for prostate cancer. This provider saw a breast cancer patient on a particular day and used the automated EMR template to document. The provider clicked that he had checked the female patient’s prostate. Since this is not possible, the provider had to mend the entry to reflect the actual services rendered to the female patient. This type of inconsistent documentation occurs quite frequently in hospice facilities.

Compliance auditors often find inconsistent documentation in the patient’s medical record chart when hospice caregivers do not follow the plan of care, or when the hospice care plan is not updated to reflect the order or services provided. For example, the nurse may document a hospice patient is totally bed bound; however, the hospice aid may document that the patient was using a walker during the visit, or that there’s an order in the care plan for bed baths, and the aid documents that the patient ambulated well in the shower, or the nurse documents a fast stage 7B (he ability to speak only a single word) and the chaplain states that the retired veteran patient verbally told him all about his days in the Air Force during the same visit day. Documentation errors of this caliber can be identified and corrected with effective coordination, communication, daily chart reviews, and interdisciplinary team meetings. The order and plan of care should always accurately reflect the condition and services rendered to the hospice patient.

Covered Items and Services

Once a patient elects and starts hospice, the hospice team will create a care plan that may include physician services, nursing services, DME services, medical supplies, and drugs for pain management. They may provide hospice aid, physical therapy, occupational therapy, speech therapy, social services, dietary counseling, spiritual and grief counseling, short- term patient care for pain and symptom management, and inpatient respite. One of the most amazing things I have experienced while working in hospice is a patient diagnosed with Alzheimer’s and the patient’s jubilant response to music therapy.

Non-Covered Services

Once a Medicare patient elects to start hospice, Medicare will not cover the following: treatment needed to cure a terminal illness or related conditions, prescription drugs that are deemed curative, care for any hospice provider that was not set up by the hospice medical team, room and board for care in the patient’s home or if the patient lives in a nursing home. If the hospice team determines the patient needs short-term, in-patient respite care services, the hospice will make the necessary arrangements and coordinate the efforts with the facility. Additionally, Medicare will not cover while the patient is under hospice care include emergency department treatment or ambulance transport; unless the care was arranged by the hospice team or is unrelated to the patient’s terminal illness or related conditions.

Durable Medical Equipment

Medicare pays for the hospice for DME and durable medical equipment for hospice beneficiaries. With efforts to create checks and balances, hospice agencies must communicate with DME suppliers to prevent the DME provider from inappropriately billing Medicare for DME supplies covered under the hospice per diem rate. DME suppliers should not bill Medicare for DME if a patient is under hospice care. It is important to note that all DME billed to Medicare after the patient’s admission date to hospice services or before the discharge of the patient from hospice services will be denied as inclusive to hospice services. The OIG’s audit estimated Medicare improperly paid $117 million over four years (from the January 2015 to April 2019 audit period) for DME provided to hospice beneficiaries.

Facility NOEs

Facility notifications are essential in preventing overlapping claims. Overlapping claims often occur when agencies fail to properly discharge beneficiaries. For example, if a patient decides to revoke and or transfer from one hospice and sign on with a different hospice agency, the receiving hospice agency must submit a signed notice of election to the current hospice agency and include the start date the beneficiary has elected to start with the new hospice agency. The hospice facility must indicate the correct admission and discharge date on their claims. The patient’s medical record chart must also include (but is not limited to) Medicare insurance eligibility certification, documentation, and communication between the current and transferring hospice facilities, the new notice of hospice election, a signed revocation document if applicable, and a signed transfer notification if the patient is transferring. Hospice agencies often contract with other institutions such as skilled nursing facilities and or home health agencies. It is important to have written contractual arrangements and a room and board notification signed by both providers as both provider types are not allowed to bill Medicare separately for contractual services while the patient is under hospice care.

GV and GW Modifiers

The GV modifier is defined as related and used by the attending physician when the services are related to the patient’s terminal condition. The attending physician is not employed, not paid, or not part of the hospice agency. For example, a patient enrolled in hospice for congestive heart failure (ICD10 code I50.9). The patient goes to the attending physician who is not associated with the hospice agency for services related to congestive heart failure. In this example, the procedure provided by the attending physician is not associated with hospice, and the services performed by the attending physician are not related to congestive heart failure. The services for the procedure code are reported with a GV modifier.

So, when we talk about the GW modifier, this is unrelated. The GW modifier should be used when a service is rendered to a patient enrolled in hospice, and the service is unrelated to the patient’s terminal admission. The use of GW modifier is for a procedure done in the physician’s office when the attending physician is not employed by the hospice and performs a service that is not related to the patient’s terminal condition. For example, the beneficiary is enrolled in hospice and goes to the physician’s office for closed treatment of a metatarsal fracture (CBT code 284). If the procedure is unrelated to the terminal prognosis (meaning non-hospice related) the physician bill should append the GW modifier services not related to the patient’s terminal condition. If the GW modifier is not appended, the procedure may be related to the terminal prognosis. The claim would be an error since the service is included with payments under the patient’s hospice benefit.

As I reviewed the OIG’s work plan to combat the upward trend in overpayments for items and services to the Medicare beneficiaries in hospice, I immediately thought, “How can we help resolve the issue? What can we do?” We can help by doing the following:

    • Communicate: Communicate with our patients, our teams, our providers, and our vendors.
    • Document: Document in real-time so that we do not solely depend on our memory to recall care delivered if something transpired. By documenting, we can effectively help by collaborating, working with our teams to address best practices, and achieving goals, by observing and paying attention to details to prevent inefficiencies.
    • Notify: Notify the proper team members to address issues that occur.
    • Follow up: Follow up, close the loop, and verify an issue has been properly resolved.

As a former manager of a hospice facility, I have always been amazed by how hospice interdisciplinary teams come together to discuss patient-centered care provided to hospice patients. These teams come together to discuss issues that they encounter, they discuss additional supplies needed to care for the patient, they discuss how the patient responds to their visit, and they also update their care plans accordingly. Their communication is so thorough, it is as if the patients were members of their own families. I remember thinking our patients are not just numbers; we really care.

Software Solutions For Auditors: Audit Manager

When I started working as a healthcare compliance auditor many years ago, we did not have a user-friendly software system like Healthicity’s Audit Manager. We had to travel to the provider’s office physically, pull medical record charts, hand score the visit using paper audit tools, create random samplings using Excel documents, and create reports using Word documents. Thanks to Healthicity’s Audit Manager, we now have a simple, efficient, and robust way of conducting cloud-based audits using a user-friendly interface, running detailed reports, and providing individual providers and organizational feedback more than ever before.

A long time ago, a physician asked me, “Why are audits performed reactively instead of proactively?” I wish I had something like Audit Manager during that time. Audit Manager has a feature under "audit projects" where you can schedule out and proactively plan your audits. This feature gives the auditor the ability to schedule multiple audits proactively after you have reviewed the OIG’s work plan. Additionally, Audit Manager has customizable documentation elements that make it easier for auditors to detect and report inconsistent documentation trends and provide timely feedback, thus improving audit efficiency by up to 40 percent. These customizable documentation fields are beneficial not only to hospice providers but also to multi-specialty providers.

Questions or Comments?

We hope you enjoyed this exploration of the OIG’s Workplan with La Tanya McNair. If you have any questions or comments about hospice benefits, recertification requirements, documentation requirements, hospice services, facility notifications (also known as NOEs), billing modifiers, or anything else related to this topic, don’t hesitate to reach out to us. If you would like to learn more about Audit Manager, you can quickly and easily schedule a free demo with one of our product experts.


To download this blog as a PDF, click the button below.

Download the PDF

Questions or Comments?