Untangling the Hospice GIP Conundrum

With heightened regulatory scrutiny and dropping utilization, hospices are walking a tightrope when it comes to providing the General Inpatient (GIP) level of care.

Though hospices are required to offer all four levels of care, more than half did not provide a single day of GIP during 2022, according to the U.S. Centers for Medicare & Medicaid Services (CMS). Utilization overall has been declining. GIP represented 1.8% of hospice care days in 2013, CMS reported. Last year, that number dropped to 0.9%.

These declines are cause for concern, Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization (NHPCO), said at the industry group’s Annual Leadership Conference.

“A lot of hospices are not providing much GIP care; 56% of hospices did not provide a single day of GIP care in 2022,” Lund Person said. “This should be a red flag for all of us. GIP care in general is something that is one of the four levels of care and is something that CMS is expecting hospices to be able to provide.”

CMS has been trying to identify issues that may be impeding patient access to GIP. Alongside a small bump in GIP reimbursement, CMS included requests for information (RFIs) in its proposed 2024 hospice rule around access barriers to these services, pointing towards claims data that reflected underutilization.

Simultaneously, CMS and other regulatory agencies have been intensifying their focus on how hospices use GIP. Scrutiny of GIP utilization has been ongoing for a number of years, dating back to 2013 reports from the OIG.

CMS and its Medicare Administrative Contractors have prioritized audits for GIP stays that are longer than seven days, though CMS has no rules that limit the time patients can receive those services. Those instances of longer stays have become the subject of a rising number of provider audits.

In addition, the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG) is conducting its own national audit of GIP, focused on Medicare claims for hospice enrollees transferred to GIP settings following an acute hospitalization.

OIG indicated that longer general inpatient hospice stays and high GIP costs precipitated the audit. The watchdog agency also cited a high incidence of improper billing associated with GIP.

Roughly one-third of Medicare GIP claims are submitted in error, the OIG reported. Inaccurate billing was among the driving forces behind the nationwide audit.

Among the causes for those errors are widespread confusion around the circumstances in which GIP is warranted, as well as incomplete or inaccurate documentation, Lauren Templeton, medical director for Hendrick Hospice Care in Abilene, Texas, said at the NHPCO conference.

“One of the big challenges we face is just not understanding what the General Inpatient level of care is. There are a lot of misconceptions,” Templeton said. “The medical necessity of that short term crisis is what demonstrates that higher level of care.”

Common misconceptions include the notion that the patient’s location equates with the level of care, according to Templeton. A patient may be staying in a hospice inpatient center, for example, but might not be receiving the GIP level of care. Another common misunderstanding is the perception that a patient needs GIP when they are actively dying, she indicated.

The essential criteria for determining GIP are medical necessity due to a short-term crisis that involves symptoms that are uncontrolled, unmanageable, severe or intractable, Templeton said at the conference.

As is often the case when it comes to regulatory compliance, clinical documentation is the linchpin.

Complete and accurate documentation is critical to avoiding or navigating GIP audits. Hospices need to consistently monitor the patient’s condition and document daily, or in some cases multiple times per day, the reasons that the individual’s symptoms could not be managed in the home.

Moreover, the documentation must be consistent across the interdisciplinary team, according to Templeton.

“The most important thing is that all members of the interdisciplinary group have got to be engaged in documentation. We need to be on the same page,” she said. “What happens when we’re not is that it leads to conflicting data in the clinical record. It starts with us engaging from the perspective that all members of the interdisciplinary group understand that we have to be exemplary at documenting this in the clinical record.”