Enhanced Controls Needed to Assure Validity of Medicare Hospice Enrollments

EXECUTIVE SUMMARY:

The objective of this report was to consolidate and present issues disclosed by our ongoing Project Operation Restore Trust (ORT) audits of Medicare hospice services. Some of the hospices which we have audited and referred to in this report are also the subject of continuing Office of Inspector General (OIG) review.

The Medicare hospice program, while highly respected and successful in its mission, is a program which has experienced a substantial number of ineligible enrollments as identified in our audits. The reviews focused on determining whether the beneficiaries met the Medicare definition of “terminally ill” at the time of enrollment in the hospice program. The audits covered 12 large hospices located in 4 ORT States (Illinois, Florida, Texas, and California). Working with us, physicians from Medicare Peer Review Organizations (PRO's) reviewed the medical files of all 2,109 long-term beneficiaries in those hospices that had been in care over 210 days, or that had been discharged from hospice at some point after reaching the 210 day threshold. The PRO physicians concluded that 1,373 of the selected beneficiaries were ineligible for hospice because, at the time of initial diagnosis, they were not terminally ill as defined by Medicare regulations, i.e,. having a life expectancy of 6 months or less (we hereinafter use the phrase "terminally ill" as defined in Medicare regulations). To date, we have issued 5 individual reports to the Health Care Financing Administration (HCFA) recommending that the Regional Home Health Intermediaries (RHHI) recover about $17.2 million for ineligible payments made to these hospices. The remaining seven hospices are pending further OIG review of their activities. Combining the findings on all 12 hospices, Medicare paid about $83 million on behalf of the 1,373 ineligible beneficiaries. Payments for some of these beneficiaries could be continuing today. For 262 additional beneficiaries reviewed, eligibility could not be established because medical evidence was missing from patient files or was incomplete. Medicare payments applicable to these 262 patients totaled about $14 million.

Although our audits covered only 12 large hospices and were focused only on long-term patients, analysis of the HCFA data base for hospice beneficiaries showed evidence of numerous long-term beneficiaries in other hospices across the country. Significant growth in the number of long-term patients admitted by hospices occurred after hospice regulations were modified to add a fourth, indefinite length, period of care for reimbursement purposes. As of February 1996, over 11,000 beneficiaries (about 14 percent of hospice beneficiaries nationwide) had been in care for more than 210 days.

These ORT reviews followed a more limited audit of hospices in Puerto Rico which noted large numbers of ineligible beneficiaries. An island-wide statistical sample in Puerto Rico disclosed that about $20 million was paid by Medicare for beneficiaries who were not terminally ill at the time of diagnosis. This amount together with our results at the selected hospices in ORT States brings the total of identified Medicare payments for ineligible recipients to more than $100 million. We recommended to HCFA that it recover about $37.2 for ineligible payments made to these hospices.

We have identified several underlying factors which we believe contributed to the problems we noted in our hospices audits.

• There has been less rigorous enforcement of the 6-month prognosis requirement by the hospice industry, especially for various noncancer diagnosed patients. This softening is most apparent in the enrollment of nursing facility residents that have chronic medical problems common to an elderly population. About 60 percent of the 1,373 ineligible beneficiaries identified during our reviews were nursing facility patients.
  
• Hospice regulations applicable to nursing home residents are complex. The regulations prohibit Medicare payments for hospice care on behalf of beneficiaries receiving Medicare funded services in skilled nursing facilities. Paradoxically, Medicare payments for hospice care are permissible when the beneficiary is receiving Medicaid funded services in a nursing facility. The joint funding by the Medicare and Medicaid programs for these nursing home residents open the possibility for abusive practices.
  
• A nationwide chain of hospices paid an amount in excess of the usual Medicaid reimbursement to nursing facilities and used marketing materials which downplayed or ignored the 6-month prognosis requirement. In addition, the chain had a large sales staff which was paid commissions in amounts based on the length of a patient's stay. These practices created a climate conducive to enrollment of hospice patients who were not terminally ill.
  
• Internal controls are weak in the areas of physician certifications of terminal illness, claims processing, and medical review at the RHHI, audit procedures at the RHHIs for "cap" report reviews, and the overall design of the reimbursement "cap" system--the method of paying hospices a maximum amount of Medicare funds based on a census count of beneficiaries enrolled.

Some of the problems noted in this report are longstanding and have been pointed out by others. A recent article in The New England Journal of Medicine concluded that patients in large and for-profit hospices have relatively long survival periods after enrollment and suggested that such hospices may encourage early enrollments to recoup the high up-front costs associated with admissions. Other questions were posed in the article regarding whether such hospices have efficient "outreach" programs or place fewer "barriers to enrollment." We believe the results of our audits as detailed in this report will help HCFA respond to these questions. Other recently issued OIG reports have highlighted vulnerabilities in the Medicare program for hospice beneficiaries residing in nursing homes.

To date, we have issued 5 individual reports to HCFA recommending that the RHHIs recover $17.2 million for payments made for ineligible beneficiaries. The remaining 7 hospices representing ineligible payments totaling $65.8 million are pending additional OIG review of their activities. In the report, we are making broader recommendations for HCFA to consider that, in our opinion, will prevent various problems or abusive practices we have identified in the hospice program from recurring. Our recommendations include:

• Reinforcing the "6-month prognosis" requirement through a direct bulletin or memorandum from HCFA to industry advocacy groups for dissemination to all hospices.
• Prohibiting the practice of hospices paying nursing facilities more for "room and board" than the hospices receive from the State Medicaid agencies on behalf of dually eligible beneficiaries.
• Informing hospices that marketing materials should prominently feature Medicare eligibility requirements and monitoring the use of sales commissions as incentives for patient recruiting.
• Making hospice physicians more accountable for their certifications of terminal prognosis by requiring that the certification-recertification forms signed by these physicians contain a statement concerning the penalties for false claims.
• Strengthening claims processing controls at the RHHIs with more focus on front-end reviews and nontraditional, suspect, or exceedingly vague diagnoses.
• Seeking legislative change for a more meaningful "cap" or maximum amount for hospice payments and instructing the RHHIs to establish standard audit procedures for these “cap” reports submitted by hospices.
• Proposing legislation to restructure the use of benefit periods so that individuals who do not need or no longer need hospice care could be discharged without prejudice to eligibility during a defined hold harmless period of program adjustments.
• Seeking a legislative amendment to make changes to the existing payment methodology for dually eligible nursing facility residents, by reducing to the lowest level necessary the Medicare hospice payment for these nursing facility patients.

The Balanced Budget Act of 1997, enacted after publication of our draft report, resulted in numerous modifications of Medicare's hospice benefit. These modifications included allowing hospices to discharge patients whose conditions improved without loss of future benefits to the hospice beneficiary (which addressed one of the above recommendations) and a new requirement for more frequent certifications of eligibility after 180 days of hospice care.

The HCFA generally concurred with the recommendations in our draft report. They noted, however, that from their readings the art of accurate predictions about terminal prognoses is not exact. Although they do not believe this negates the findings overall (giving recognition to the PROs that reviewed our cases), they noted there could be some degree of inaccuracy in some of the individual cases found ineligible. We appreciate the state of the art, but we have no reason to dispute the medical opinion of the PRO reviewers who determined that 1,373 beneficiaries were not terminally ill as defined by HCFA.

We have paraphrased HCFA's response after each recommendation in the Results of Review section of the report and have added our additional comments, where appropriate.

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