OIG Planning for Nationwide Hospice Eligibility Audit in 2023

A nationwide audit of hospice eligibility, with a focus on Medicare beneficiaries who have not had an inpatient ER or hospital stay prior to starting hospice care is planned for 2023 by the Office of the Inspector General (OIG) of the Department of Health & Human Services.

According to OIG, previous compliance audits on hospice providers “identified findings related to beneficiary liability.” This indicates those findings are at least partially responsible for the planned coming audit.

“[I]n the last couple of years, our agency has done numerous individual hospice audits, and every one of them found issues with beneficiary eligibility,” an OIG spokesperson told Hospice News.

Hospice eligibility is one of the most frequently targeted issues in regulatory enforcement.

According to a report from 2021 from Bass, Barry, and Sims, one of the leading causes of hospice fraud involves hospices billing Medicare for services for patients that were not eligible for those services.

The focus appears to be on patients admitted to hospice without a preceding hospitalization or ER visit, which might indicate a focus on patients with diagnoses of heart disease, chronic kidney problems, or dementia. Some hospices have reported that during the current public health emergency their referral mix has changed, with more coming from physician offices and fewer from hospitals.

Two OIG reports on hospice in 2019 alarmed some in Congress and CMS reformed its survey process last year to include new provisions for surveyor training and greater consumer transparency.

Medicare Administrative Contractor Cost Report Oversight – Contract Review

OIG also announced a Medicare Administrative Contractor Cost Report Oversight – Contract Review, with a report expected to be issued in FY 2023.

In accordance with their CMS contracts, Medicare administrative contractors (MACs) are responsible for accepting, auditing, and settling provider Medicare cost reports. The MAC performs desk reviews of all cost reports and audits as warranted prior to settlement of the cost report to determine adequacy, completeness, and accuracy and reasonableness of the data in the cost report. CMS will review the MACs cost report oversight by verifying the number of desk reviews and the number of audits performed in accordance with the CMS contract and identify non-compliance issues.

Following this review, CMS will conduct additional reviews that will include MAC audit findings and recommendations to determine whether the provider implemented the recommendations and took corrective action.

Finally, CMS will examine CMS’s oversight of the MAC cost report desk reviews/audits. The objective of the audit is to determine whether the individual MACs met requirements stated in the MAC contracts.