Medicare overbilled by hospices, paying for some drugs twice

Unnecessary care is costing more than $260 million per year, according to a Department of Health and Human Services investigation.
By Stephen Feller  |  April 4, 2016 at 2:06 PM
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WASHINGTON, April 4 (UPI) -- Nearly one-third of hospice billing to Medicare is inappropriate or unnecessary, according to a report from the U.S. Department of Health and Human Services.

The HHS Inspector General report on hospice billing, released today, found Medicare was billed inappropriately for $268 million in 2012 for hospice general inpatient care.

The misuse of funds includes care being billed but not provided and care given to beneficiaries they don't need, including commonly billing for general inpatient care when patients did not have unmanaged symptoms or uncontrolled pain.

In the report, the agency says it has long had concerns about hospice beneficiaries and previous reports found oversight lacking, and rampant problems with patient care planning and quality.

Hospice care is meant to help terminally ill patients with six months or less to live continue their lives comfortably, rather than trying to cure diseases. Medicare pays hospices $720 per day, with the expectation it covers all expenses, and limits routine home care payments to $187 per day.

For the most part, hospice care is provided at home, but some patients with more serious illnesses need to be in a hospital or managed care facility. General inpatient care is the second most expensive level of hospice care and is meant to be short-term to control pain and symptoms.

HHS Inspector General Daniel Levinson told the New York Times he found beneficiaries did not need inpatient care in about 20 percent of claims for inpatient care, and another 10 percent beneficiaries only needed the additional care for part of the inpatient stay, adding that "in 1 percent of stays there was no evidence that the beneficiary elected hospice care or was even certified as having a terminal illness."

Photo by Office of Inspector General/U.S. Department of Health and Human Services

The agency analyzed data from a sample of all general inpatient care stays during 2012, estimating inappropriate billing, using Medicare Part D data to identify drugs billed to both Part D and for hospice services.

Overall, 31 percent of billing -- $268 million -- was deemed inappropriate, broken down by how little a need patients had. For-profit hospices were more likely than others to bill inappropriately, with Medicare sometimes paying twice for drugs that should have been covered under the daily payment rate. The report also found hospices don't meet care planning requirements for 85 percent of beneficiaries.

Among the inappropriate stays was one from a patient with a circulatory disease who could have been treated at home but instead was treated at a facility for 46 consecutive days for a cost to Medicare of $31,000, HHS said in a press release. In another case, a hospice provided care to a beneficiary with dementia for 16 days but did not treat his pain.

"The findings in this report make clear the need to address the misuse of GIP and hold hospices accountable when they bill inappropriately or provide poor-quality care," the agency said in the report, recommending increased oversight of hospices, more reviews of billing and payments, and better methods of enforcement and follow-up for hospices that perform poorly.

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