OIG Study Faults GIP Hospice Stays

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By Rhonda Oakes, RN/CHPN 
Regulatory Analyst, Change Healthcare
OIG Watching Hospice General Inpatient Stays

For the second time this year, the Office of Inspector General (OIG) has focused on hospice general inpatient (GIP) stays. For most hospice organizations, this report did not shed light on any new gotcha’s. Hospices know the importance of defensible documentation. It is evident the government will continue to closely monitor the general inpatient level of care.

The September OIG report was based on the same 565 Medicare GIP stays that were analyzed for the March report. The latest report found that 35% were missing an adequate Notice of Election (NOE) statement and that physician narratives were either missing or inadequate in 14% of records studied.

It’s important that patients fully understand that hospice care is palliative rather than curative in nature, which is the basis of the hospice election statement. And since hospice care requires a physician certification, that must be part of the patient record.

The reimbursement difference between routine home care and inpatient care is more than 300%, with no more than $187 a day for home care compared to $720 a day for a GIP stay.

Building on Earlier Report

The OIG first broached this issue with a report in March that called 31% of GIP stays inappropriate and cost the government $268 million in unnecessary care. Both reports were based on a stratified random sample of hospice GIP stays during 2012.

Both empirical and anecdotal evidence point to the value of hospice to improve patient quality of life at the end of life while also saving payers money. Talk about hospice care is no longer taboo, with a landmark report from the Institute of Medicine (IoM) showing that nine out of 10 Americans believe it is critical to discuss end-of-life issues with family members.

The Centers for Medicare & Medicaid Services (CMS) cited the IoM report as partial justification for agreeing to pay physicians for advance care planning services for patients, which began in January 2016.

As a result of the September report, the OIG recommended that CMS:

  • Develop and disseminate model text for election statements
  • Instruct surveyors to strengthen their review of election statements and certifications of terminal illness
  • Educate hospices about election statements and certifications of terminal illness
  • Provide guidance to hospices regarding the effects on beneficiaries when they revoke their election and when they are discharged from hospice care.

CMS agreed with the first three recommendations and stated no opinion on the fourth.

Emphasis on Documentation

Both OIG reports hit hard on the issue of documentation – the documentation of a terminal illness by the physician and the Notice of Election by the patient. For hospice organizations of any size, keeping track of the required documentation can be a challenge while meeting the daily needs of patients. When using custom forms, it’s critical that the language is reviewed and updated with current regulations. Hospice providers need to be aware that one missing or misplaced word can result in a denial. The recommendation for CMS to develop and disseminate model text for elections statements is a step in the right direction.

As the OIG notes in the September report, “Together, the election statement and certification of terminal illness (CTI) provide critical safeguards to ensure that the beneficiary understands the hospice benefit and that the physician is involved in determining whether the beneficiary is appropriate for hospice care.”

All healthcare providers are being asked to better document not only the care they provide, but increasingly, the justification for that care. Hospice organizations would benefit from a deep dive into their documentation to help ensure it meets both the letter of the law and the spirit of the law. And having a hospice automation system that effectively tracks the required documents, including the NOE and CTI, can help keep your agency in regulatory compliance.

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