Review of Medicare Hospice Beneficiary Eligibility in the Commonwealth of Puerto Rico

EXECUTIVE SUMMARY:

This final audit report points out that, based on the results of a statistical sample of patient records, approximately $19.7 million was improperly paid to 37 hospice providers in Puerto Rico on behalf of ineligible beneficiaries during the period September 1991 through July 1994. The beneficiaries were ineligible for hospice care primarily because their medical condition was nonterminal. In addition to financial adjustments, we recommended that the Health Care Financing Administration (HCFA) instruct the intermediary to improve its claims processing controls by establishing a "front-end" diagnosis based edit to identify suspect claims and conducting medical record reviews of the suspect claims. The HCFA concurred with our findings and recommendations.