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: Medicare Payments Made Outside of the Hospice Benefit

Announced on  | Last Modified on  | Series Number: W-00-24-35797
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

According to 42 CFR 418.24(d), in general, a hospice beneficiary waives all rights to Medicare payments for any services that are related to the treatment of the terminal condition for which hospice care was elected. The hospice agency assumes responsibility for medical care related to the beneficiary's terminal illness and related conditions. Medicare continues to pay for covered medical services that are not related to the terminal illness. Prior OIG reviews have identified separate payments that should have been covered under the per diem payments made to hospice organizations. We will produce summary data on all Medicare payments made outside the hospice benefit, without determining the appropriateness of such payments, for beneficiaries who are under hospice care. In addition, we will conduct separate reviews of selected individual categories of services (e.g., durable medical equipment, prosthetics, orthotics and supplies, physician services, outpatient) to determine whether payments made outside of the hospice benefit complied with Federal requirements.

There are 4 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (1)

Project OAS-25-09-009 • Announced on May 1, 2024

COMPLETED PROJECTS IN THIS SERIES (3)

Medicare Program Oversight

Project A-09-23-03024 • Completed on November 12, 2024

Review of Payments Overlapping Hospice

Project A-09-20-03015 • Completed on February 14, 2022

Medicare Program Oversight

Project A-09-20-03026 • Completed on November 16, 2021

TIMELINE

  • February 15, 2020
    Series Number W-00-24-35797 Assigned
  • February 15, 2020
    Project Announced

    Medicare Program Oversight - A-09-20-03026

  • February 26, 2020
    Project Announced

    Review of Payments Overlapping Hospice - A-09-20-03015

  • November 16, 2021
    Project Complete - A-09-20-03026

    Medicare Program Oversight has been marked as complete. This audit resulted in 5 recommendations.

  • February 14, 2022
    Project Complete - A-09-20-03015

    Review of Payments Overlapping Hospice has been marked as complete. Report Published

  • October 11, 2022
    Project Announced

    Medicare Program Oversight - A-09-23-03024

  • May 1, 2024
    Project Announced

    Project OAS-25-09-009

  • November 12, 2024
    Project Complete - A-09-23-03024

    Medicare Program Oversight has been marked as complete. This audit resulted in 6 recommendations.

  • Today
    1 Audit In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

3 REPORT PUBLISHED

Medicare Improperly Paid Suppliers an Estimated $117 Million Over 4 Years for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Provided to Hospice Beneficiaries (A-09-20-03026)

22-A-09-014.01 to CMS - Closed Implemented
Closed on 09/29/2022
We recommend that the Centers for Medicare & Medicaid Services take the following actions for supplier claims for DMEPOS items provided to hospice beneficiaries, which could have saved Medicare an estimated $116.9 million in improper payments and could have saved beneficiaries an estimated $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during the audit period.

22-A-09-014.02 to CMS - Closed Implemented
Closed on 03/01/2022
We recommend that the Centers for Medicare & Medicaid Services improve the CWF prepayment edit process by instructing the DME Medicare contractors to deny DMEPOS claims submitted by suppliers without the GW modifier for DMEPOS items provided to hospice beneficiaries.

22-A-09-014.03 to CMS - Open Unimplemented
Update expected on 06/14/2024
We recommend that the Centers for Medicare & Medicaid Services implement a postpayment edit process to detect claims submitted by suppliers processed before a beneficiary's notice of election of hospice care is processed in the CWF, and instruct the DME Medicare contractors to deny DMEPOS claims identified by the edit process if they do no have the GW modifier.

22-A-09-014.04 to CMS - Closed Implemented
Closed on 02/03/2023
We recommend that the Centers for Medicare & Medicaid Services direct the DME and hospice Medicare contractors, or other contractors as appropriate, to: (1) conduct prepayment or postpayment reviews of supplier claims for DMEPSO items provided to hospice beneficiaries and billed with the GW modifier, and (2) analyze Medicare claims data to probe and educate suppliers that use the GW modifier inappropriately.

22-A-09-014.05 to CMS - Open Unimplemented
Update expected on 01/22/2026
We recommend that the Centers for Medicare & Medicaid Services study the feasibility of including palliative items and services not related to a beneficiary's terminal illness and related conditions within the hospice per diem. Such a requirement would eliminate the need for Medicare to make additional payments for these services consistent with CMS's longstanding position that payments for services unrelated to a beneficiary's terminal illness and related conditions should be exceptional, unusual, and rare given the comprehensive nature of the services covered under the Medicare hospice benefit. In analyzing the feasibility of such a change, CMS could consider: (1) beneficiary access to care, (2) administrative costs, (3) appropriate adjustments to the per diem rates to reflect the higher costs associated with providing hospice services, and (4) possible improvement of coordination of care.

View in Recommendation Tracker

Medicare Improperly Paid Acute-Care Hospitals an Estimated $190 Million Over 5 Years for Outpatient Services Provided to Hospice Enrollees (A-09-23-03024)

25-A-09-011.01 to CMS - Open Unimplemented
Update expected on 11/16/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Improve system edit processes to help reduce improper payments for outpatient services provided by acute-care hospitals to hospice enrollees.

25-A-09-011.02 to CMS - Closed Implemented
Closed on 05/16/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Educate acute-care hospitals to understand that each hospice enrollee's hospice election statement addendum is available on request, and educate hospices to provide the addendum if requested to help an acute-care hospital assess whether an outpatient service palliated or managed an enrollee's terminal illness and related conditions.

25-A-09-011.03 to CMS - Closed Implemented
Closed on 05/16/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Continue to educate hospices that they should be providing to enrollees virtually all necessary services that palliate or manage terminal illnesses and related conditions either directly or through arrangements.

25-A-09-011.04 to CMS - Closed Implemented
Closed on 05/16/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Educate acute-care hospitals to analyze not only whether outpatient services palliated or managed enrollees' terminal illnesses but also whether outpatient services palliated or managed a condition related to a terminal illness.

25-A-09-011.05 to CMS - Closed Implemented
Closed on 04/28/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Clarify the language in the Manual (chapter 11, section 50), and in other CMS or MAC guidance documents or educational initiatives, if necessary, to specifically mention "related conditions" so that the language is consistent with Federal regulations and the Federal Register in stating that services not related to enrollees' terminal illnesses and related conditions may be billed to Medicare with condition code 07.

25-A-09-011.06 to CMS - Closed Implemented
Closed on 03/28/2025
We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Direct MACs or other appropriate contractors, such as Recovery Audit Contractors, to: (1) analyze Medicare claims data to identify acute-care hospitals that have aberrant billing patterns for condition code 07, and conduct Targeted Probe and Educate reviews of these acute-care hospitals; and (2) conduct prepayment or postpayment reviews of acute-care hospital claims for outpatient services provided to hospice enrollees and billed with condition code 07.

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