- Audit finds 70% of sample violated Medicare requirements
- Hospitals billed for care covered by hospice, HHS OIG says
Acute care hospitals received over $190 million in improper Medicare payments for outpatient hospice services, government watchdogs say.
An audit report released Monday by the US Department of Health and Human Services Office of Inspector General sampled over $283.7 million in Medicare Part B payments for outpatient services furnished by acute care hospitals to hospice patients from 2017 through 2021. The audit found that 70 out of the 100 services sampled by the agency did not comply with federal requirements.
The OIG noted in the audit that payments were made to acute-care hospitals for palliative care that were âalready covered as part of the hospicesâ per diem payments and should have been provided directly by the hospices or under arrangements between the hospices and acute-care hospitals.â
The OIG claims that this occurred due to factors including not having enough details in Medicare guidance, Medicare contractors not conducting prepayment and post-payment reviews, and not having a properly designed prepayment edit process.
Based on the sample, the OIG estimates that Medicare âcould have saved $190.1 millionâ if âpayments had not been made to acute-care hospitals that provided outpatient services to hospice enrollees for services related to the palliation and management of the enrolleesâ terminal illnesses and related conditions.â
Additionally, the OIG estimated that enrollees âcould have saved $43.6 million in deductibles and coinsurance that may have been incorrectly collected.â
The OIG made six recommendations to the Centers for Medicare & Medicaid Services, including improving system edit processes; educating hospitals to discern whether outpatient services palliated or managed conditions related to enrolleesâ terminal illnesses; and clarifying Medicare guidance to specifically mention ârelated conditions.â
The CMS agreed with five of six recommendations but did not agree with the OIGâs first recommendation. The agency said it was concerned about the feasibility and effectiveness of the OIGâs proposed modifications to the system edits described in the report.
After reviewing the CMSâs comments, the OIG updated its first recommendation to the CMSâs system edit processes to help reduce improper payments in the future.
Medicare Paid Hospitals $190 Million in Improper Hospice Claims
bgov.com
November 19, 2024 9:16 am
Acute care hospitals received over $190 million in improper Medicare payments for outpatient hospice services, government watchdogs say.
An audit report released Monday by the US Department of Health and Human Services Office of Inspector General sampled over $283.7 million in Medicare Part B payments for outpatient services furnished by acute care hospitals to hospice patients from 2017 through 2021. The audit found that 70 out of the 100 services sampled by the agency did not comply with federal requirements.
The OIG noted in the audit that payments were made to acute-care hospitals for palliative care that were âalready covered as part of the hospicesâ per diem payments and should have been provided directly by the hospices or under arrangements between the hospices and acute-care hospitals.â
The OIG claims that this occurred due to factors including not having enough details in Medicare guidance, Medicare contractors not conducting prepayment and post-payment reviews, and not having a properly designed prepayment edit process.
Based on the sample, the OIG estimates that Medicare âcould have saved $190.1 millionâ if âpayments had not been made to acute-care hospitals that provided outpatient services to hospice enrollees for services related to the palliation and management of the enrolleesâ terminal illnesses and related conditions.â
Additionally, the OIG estimated that enrollees âcould have saved $43.6 million in deductibles and coinsurance that may have been incorrectly collected.â
The OIG made six recommendations to the Centers for Medicare & Medicaid Services, including improving system edit processes; educating hospitals to discern whether outpatient services palliated or managed conditions related to enrolleesâ terminal illnesses; and clarifying Medicare guidance to specifically mention ârelated conditions.â
The CMS agreed with five of six recommendations but did not agree with the OIGâs first recommendation. The agency said it was concerned about the feasibility and effectiveness of the OIGâs proposed modifications to the system edits described in the report.
After reviewing the CMSâs comments, the OIG updated its first recommendation to the CMSâs system edit processes to help reduce improper payments in the future.