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Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care

Nancy Harrison, Deputy Regional Inspector General for the Office of Evaluation and Inspections, is interviewed by Jodi Nudelman, Regional Inspector General for the Office of Evaluation and Inspections in New York City.

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[Jodi Nudelman] I'm Jodi Nudelman, Regional Inspector General for the Office of Evaluation and Inspections, speaking with Nancy Harrison, Deputy Regional Inspector General, about a report called "Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care." First, Nancy, can you tell me what General Inpatient Care is?

[Nancy Harrison] Sure. Terminally ill Medicare beneficiaries, who are expected to live for six months or less, usually get hospice services at home. If pain or other symptoms become too difficult to manage at home, a patient may need to go to a medical facility. This could be a skilled nursing facility, a hospital, or a hospice inpatient unit. The purpose of hospice general inpatient care is to get symptoms under control.

[Jodi Nudelman] So are hospices using general inpatient care correctly?

[Nancy Harrison] Many are not. Hospices billed one-third of these stays inappropriately. In many cases, patients did not need inpatient services at all because they didn't have unmanaged symptoms. Or, they needed inpatient care at some point, but received it for much longer than necessary.

[Jodi Nudelman] So can you give me an example?

[Nancy Harrison] Sure. One hospice billed for general inpatient care for a patient whose symptoms were managed with oral medication. The physician even noted that the patient should return to routine home care, but, the hospice billed for inpatient care for two weeks longer than needed.

[Jodi Nudelman] What else did you find?

[Nancy Harrison] We found that for-profit hospices were more likely than other hospices to bill for general inpatient care inappropriately. We also found that almost half the general inpatient stays provided in skilled nursing facilities were inappropriate.

[Jodi Nudelman] So, how much does this cost in total?

[Nancy Harrison] In 2012, inappropriate billing for general inpatient care cost Medicare $268 million dollars. At the time of this study, Medicare paid $672 per day for general inpatient care, compared to $151 per day for routine home care.

[Jodi Nudelman] So there are clearly financial issues, what about quality of care?

[Nancy Harrison] Yes. Hospices did not meet care planning requirements for 85 percent of general inpatient stays. Often, the hospice did not involve the right people in care planning, like a counselor or social worker. Care plans were missing key information, like the amount of services a patient needed. That can put patients at risk of receiving inadequate services or treatment that they don't need.

[Jodi Nudelman] Did you find any specific examples of quality of care concerns?

[Nancy Harrison] We did. I'll give you an example. A for-profit hospice was caring for a 101-year old patient with dementia. He had uncontrolled pain throughout his 16 days in general inpatient care. The hospice did not change his pain medication until the last day and did not provide him the special mattress he needed for more than a week.

[Jodi Nudelman] That's truly concerning. Do you have another examples?

[Nancy Harrison] In another case, a hospice billed for 17 days of general inpatient care, but did not even visit the patient. Instead, the hospice called the family to see how the person was doing. In both of these examples, Medicare spent thousands of dollars, yet the two patients may not have been well served.

[Jodi Nudelman] So what are you recommending that the Centers for Medicare and Medicaid Services, or CMS, do?

[Nancy Harrison] CMS needs to hold hospices accountable for inappropriate billing, poor quality care, and the misuse of general inpatient care. CMS should ensure that a physician is involved in the decision to use general inpatient care, perhaps requiring a physician order. CMS should also conduct a review for lengthy general inpatient stays, to determine if the stay is appropriate.

[Jodi Nudelman] Do you have any more recommendations?

[Nancy Harrison] Yes. Currently, CMS's only enforcement remedy against poorly performing hospices is to terminate them from the Medicare program. But problems with care planning and quality may not always warrant termination, which leaves CMS without enforcement options. CMS should establish additional, less severe remedies to address poor hospice performance. Such intermediate options could be used to help hospices improve and ensure that beneficiaries have access to the services they need.

[Jodi Nudelman] So did CMS agree with your recommendations?

[Nancy Harrison] Yes, CMS agreed with all our recommendations.

[Jodi Nudelman] Nancy, thank you so much for sharing this important work.