OIG’s Hospice GIP Audit Fueled by Inappropriate Billing; Nearly One-Third of Claims Have Errors

Increased regulatory and clinical oversight is needed to address common billing and documentation errors related to hospice general inpatient care, according to the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG).

Inaccurate billing was among the driving forces behind the OIG’s recently announced nationwide audit of general inpatient hospice services (GIP), the regulatory watchdog stated.

Roughly one-third of Medicare claims for general inpatient hospice services (GIP) are billed in error, the OIG indicated. Common errors include billing for GIP services when hospice patients did not need this level of care.

“GIP care is solely for pain control or acute or chronic symptom management that cannot be provided in other settings,” OIG representatives told Hospice News in an email. “The report team completed some preliminary data analysis and selected a frame of claims believed to be at a high risk of misbilling. Our work has shown that in the past, hospices have inappropriately billed one-third of GIP stays, including billing for GIP care when the patient needed only routine home care or when the patient’s caregiver was not available and inpatient respite care was needed.”

Longer general inpatient hospice stays and high-cost concerns are reasons for the audit, dubbed the “Audit of Selected, High-Risk Medicare Hospice General Inpatient Services,” according to OIG. The audit will concentrate on Medicare claims for hospice enrollees transferred to general inpatient care settings following an acute hospitalization.

Through the audit, the OIG will determine whether hospice providers that billed for general inpatient care complied with Medicare requirements.

“Hospice general inpatient services claims occur when a geometric length of stay is reached for a Medicare enrollee,” OIG representatives said. “The hospital may no longer have an incentive for the patient to remain in an inpatient stay and, therefore, may want to admit them to hospice when that may not be the appropriate setting.”

An OIG study of hospice billing claims submitted during 2012 found that 31% of the GIP claims that providers submitted to CMS were inappropriately billed — to the tune of an estimated $268 million that year alone.

For example, in some cases hospices incorrectly bill for GIP services when patients do not have uncontrolled or unmanaged symptoms, the regulatory agency stated. In other instances, billing errors occurred when GIP services were provided when patients’ care needs could have been managed in a home setting.

Additionally, hospices are “more likely to inappropriately bill for GIP care provided in skilled nursing facilities than in other settings,” OIG representatives said in the email.

The U.S. Centers for Medicare & Medicaid Services (CMS) in its recently proposed 2024 hospice payment rule included a series of requests for information (RFIs) that included questions about patient utilization of high-cost, complex care. This included questions related to general inpatient settings

Increased regulatory oversight could help improve billing accuracy and compliance, the OIG indicated.

The OIG has made the following recommendations to CMS that specifically address hospice GIP care:

1. CMS should ensure that a physician is involved in the decisions to start and continue GIP care.
2. CMS should increase oversight of GIP care claims and focus particularly on such provided in skilled nursing facilities, given the higher rate at which these stays were inappropriate.
3. CMS should implement a comprehensive prepayment review strategy to address lengthy GIP care stays so that patients do not have to endure unnecessarily long periods of time in which their pain and symptoms are not controlled.

Hospice providers are required and encouraged to offer GIP care, but concerns have mounted under increased regulatory scrutiny around these services.

Case in point, longer GIP stays that exceed one to two weeks can garner regulatory attention, according to Erin Burns, senior associate in hospice and palliative care at Husch Blackwell. Longer stays and expensive GIP services can signal maleficence as regulators keep watch for bad actors in the hospice industry, Burns said.

“GIP is one of the most expensive levels of care and hospices get paid more for providing it,” Burns told Hospice News. “One thing that’s going to throw up a red flag is if you have a patient that’s receiving GIP services for more than a week or two weeks. The government has previously said they want hospice providers to be offering more GIP services and asking why they don’t. Well, this is the reason. They risk audits and being targeted by regulators.”