FWA Briefs

Find news and solutions for healthcare payers and providers. Recognize and avoid potential fraud, waste, and abuse scenarios. Real-time clinical claim editing are analyzed to maximize provider reimbursements.

The Federal Hospice Fraud Problem in the United States

  • by Steve Nesnidal, MD, CPC, AHFI
  • Jun 25, 2024, 08:08 AM
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Fraud, Waste and Abuse (FWA) in Hospice is a significant US Healthcare problem. CMS provides a fact sheet, with an overview for Hospice Providers1  Hospice Fraud not only impacts Medicare and Medicaid, but it affects Commercial Health Plans as well.

A recent US Attorney’s Office press release announced a jury conviction involving 47 million dollars of fraudulent claims involving federal hospice funds.This fraudster used a multi-faceted approach to commit hospice fraud.  First, some of the claims reviewed were submitted for beneficiaries that did not qualify for hospice services, as they did not have terminal conditions, and/or they were not certified for hospice care.  Second, some of the hospice services were submitted as General Inpatient Hospice Care (GIP) --revenue code 0656 with HCPCS codes Q5003-Q5009-- even though they did not receive inpatient hospice.  This submission approach was used simply to maximize payment, as the reimbursement rate for GIP care, submitted under the Revenue Code of 656, is the second highest daily rate that Medicare pays for hospice services.  This rate is second only to the rate for Revenue Code 652, which is Continuous Home Care3.  Third, this fraudster submitted secondary procedure codes without medical record support at a significantly higher frequency than typically seen on hospice claims. Upon audit, discrepancies were found that failed to support CPT 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, 85 minutes), 99233 (Subsequent hospital inpatient or observation care, per day…50 minutes) and 99350 (Home or residence visit for the evaluation and management of an established patient,…60 minutes).

This case provides some details that can help direct your Health Plan’s FWA Audit Plan regarding what to review within Hospice medical records: 1) Confirm the beneficiary’s terminal medical condition has been certified.  2.) Monitor for a pattern of abuse of GIP hospice services. 3.) Monitor for unsupported, high frequency submission of Evaluation and Management (E/M) codes, especially a.) Hospital Inpatient/Observation codes for admit and discharge on same date, b.) Subsequent hospital inpatient or observation care, as well as c.) codes for Home/residence visit of established patient.

C4H’s suite of software edits detects multiple types of code level discrepancies at the claim level.  Our FWA Reports analyze batches of claims for high level code abuse, allowing the user to select the key report parameters of interest, including code(s), DOS, and provider.  This allows our user to scrutinize claims data from multiple angles, the optimal approach to monitor for fraud.

For more information about CONTEXT4 HEALTH PLANS SUITE™ which contains an effective variety of FWA Reports as well as the full spectrum of up-to-date claims edits, view our webpage at this link: https://www.context4healthcare.com/health-industries/payers

References

  1. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/hospice-provideroverview-factsheet.pdf 
  2. https://www.justice.gov/usao-edla/pr/jury-convicts-hospice-owner-defrauding-medicare
  3. https://oig.hhs.gov/oei/reports/oei-02-10-00491.pdf

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