Skip to main content
U.S. flag

An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

Beta This is a new resource

Series: Review of Hospice Inpatient and Aggregate Cap Calculations

Announced on  | Last Modified on  | Series Number: W-00-24-35826
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Hospice care can provide great comfort to beneficiaries, families, and caregivers at the end of a beneficiary's life. To ensure that hospice care does not exceed the cost of conventional medical care at the end of life, Medicare imposes two annual limits to payments made to hospice providers: the inpatient cap and the aggregate cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20 percent of a hospice's total Medicare patient care days, and a hospice must refund to Medicare any payment amounts in excess of the inpatient cap. The aggregate cap limits the total aggregate payments that any individual hospice can receive in a cap year to an allowable amount based on an annual per-beneficiary cap amount and the number of beneficiaries served. Any amount paid to a hospice for its claims in excess of the aggregate cap is considered an overpayment and must be repaid to Medicare. Medicare administrative contractors (MACs) oversee the cap process and hospices must file their self-determined aggregate cap determination notice with their MAC no later than 5 months after the end of the cap year and remit any overpayment due at that time.

There are 2 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (2)

Review of CGS Hospice Inpatient and Aggregate Cap Calculations

Project A-06-23-09003 • Completed on November 27, 2024

National Government Services, Inc.

Project A-06-21-08004 • Completed on November 17, 2022

TIMELINE

  • November 17, 2022
    Project Complete - A-06-21-08004

    National Government Services, Inc. has been marked as complete. This audit resulted in 3 recommendations.

  • March 6, 2023
    Series Number W-00-24-35826 Assigned
  • March 6, 2023
    Projects Announced

    National Government Services, Inc. - A-06-21-08004

  • Review of CGS Hospice Inpatient and Aggregate Cap Calculations - A-06-23-09003

  • November 27, 2024
    Project Complete - A-06-23-09003

    Review of CGS Hospice Inpatient and Aggregate Cap Calculations has been marked as complete. This audit resulted in 3 recommendations.

  • November 27, 2024
    Series Complete

    Review of Hospice Inpatient and Aggregate Cap Calculations has been marked as complete.

2 REPORT PUBLISHED

National Government Services, Inc., Accurately Calculated Hospice Cap Amounts but Did Not Collect All Cap Overpayments (A-06-21-08004)

23-A-06-015.01 to CMS - Closed Unimplemented
Closed on 05/22/2024
We recommend that NGS collect $2,160,587 in lookback overpayments and return $22,576 in lookback refunds resulting from 2019 hospice cap calculations for lookback years.

23-A-06-015.02 to CMS - Closed Implemented
Closed on 04/04/2024
We recommend that NGS discontinue its internal policy of waiving certain overpayment collections related to lookback years and start collecting all hospice cap overpayments and paying refunds in accordance with CMS requirements.

23-A-06-015.03 to CMS - Closed Implemented
Closed on 04/04/2024
We recommend that NGS change its instructions on the cap determination notices to follow the CMS requirement that hospices remit overpayments at the time they submit their cap determination notice.

View in Recommendation Tracker

CGS Administrators, LLC, Did Not Reopen and Recalculate Most Selected Hospices’ Caps for Years Prior to 2020 (A-06-23-09003)

25-A-06-020.01 to CMS - Closed Implemented
Closed on 03/26/2025
We recommend that CGS Administrators, LLC discontinue its practices that limit the reopening of prior years' cap calculations and start reopening all prior years' cap calculations.

25-A-06-020.02 to CMS - Closed Implemented
Closed on 03/26/2025
We recommend that CGS Administrators, LLC revise its policies and procedures so that it meets the reopening deadlines established in Federal requirements.

25-A-06-020.03 to CMS - Closed Implemented
Closed on 03/26/2025
We recommend that CGS Administrators, LLC conduct the prior years' hospice cap calculations for the five hospices with UPIC recoupments and collect any additional overpayments.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship Non-institutional care
Target Groups
-
Financial Groups
Medicare A