Report Materials
Why OIG Did This Audit
- The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care.
- Previous Office of Inspector General audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.
- This audit report, part of a series of hospice compliance audits, determined whether hospice services provided by Hospice of the Valley – West (HOV) complied with Medicare requirements.
What OIG Found
- HOV complied with Medicare billing requirements for 85 out of the 100 hospice claims we reviewed. However, the remaining 15 claims did not comply with Medicare requirements, resulting in overpayments totaling $69,184 from July 1, 2020, through June 30, 2022 (audit period).
- The errors occurred primarily because HOV did not always follow its policies and procedures to prevent the incorrect billing of Medicare claims for hospice services.
- On the basis of our sample results, we estimated that, of the $86 million Medicare paid HOV, HOV received at least $8.6 million in unallowable Medicare reimbursement for hospice services for the audit period.
What OIG Recommends
We made three recommendations, including that HOV refund to the Federal Government the $8.6 million in estimated overpayments. Our complete recommendations are found in the audit report.
HOV did not concur with any of our recommendations.
26-A-09-086.01 to CMS - Open Unimplemented
Update expected on
01/27/2027
We recommend that HOV refund to the Federal Government the estimated $8,614,887 in overpayments for claims for hospice services that did not comply with Medicare requirements, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.
26-A-09-086.02 to CMS - Open Unimplemented
Update expected on
01/27/2027
We recommend that HOV consider conducting one or more internal audits or investigations for claims after our audit period, based on the findings identified by this audit, to identify any similar overpayments the provider might have received and return any identified overpayments to the Medicare program.
26-A-09-086.03 to CMS - Open Unimplemented
Update expected on
01/27/2027
We recommend that HOV provide additional training to clinical personnel on its policies and procedures to continually validate that the enrollees met the requirements for hospice (i.e., terminal prognosis of a life expectancy of 6 months or less if the terminal illness ran its normal course and the enrollees received the appropriate level of care).
View in Recommendation Tracker
Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.