Review of Hospice Beneficiary Eligibility At Hospicio en el Hogar de Manati

EXECUTIVE SUMMARY:

This review, which included a medical evaluation of the hospice's eligibility determinations for 111 beneficiaries, showed that 78 (70 percent) of those determinations were incorrect. As a result, the hospice claimed and improperly received Medicare reimbursements totaling about $1.6 million. Although we did not find a reasonable explanation for the hospice's high rate of error in eligibility determinations, we did determine that for the majority of the time period covered by our review, claims processing controls at the Medicare fiscal intermediary (FI) were not entirely adequate. We recommended that the FI improve its claims processing controls through the incorporation of edits to detect and prevent payments on behalf of ineligible hospice beneficiaries. Regarding the $1.6 million of improper Medicare reimbursements, we referred this matter to the OIG's Office of Investigations for additional investigation prior to the FI initiating recovery action on the identified overpayments.