Author: Harper Dion
Posted: February 7, 2023
Since the onset of the pandemic, the use of Hospice agencies has changed drastically. Overcrowded and understaffed hospitals increased patient desire to receive care at home or transition to smaller hospice organizations for peaceful end-of-life care. However, the increase of awareness and usage of facilities comes with issues of its own. According to a 2021 report by Bass, Barry, and Sims, the leading cause of post-acute fraud stems from hospices billing Medicare for services in which patients were not eligible.1 This fraud has led to multiple multi-million-dollar settlements, and the repeated issues it brings finally demanded a response from the Office of the Inspector General (OIG).
In early 2022, the OIG unveiled plans for a nationwide hospice eligibility audit; this audit is set to begin now in 2023.1 Following a holistic review of the industry, the audit will be completed by September 2023, likely by an Independent Medical Review Contractor (IMRC) contracted by OIG.2 Audits are based upon industry-wide data, focused mainly on inaccuracies within Medicare and Medicaid. In light of this, hospice agencies will experience a heavy review. Unfortunately, many common practices can raise OIG red flags. Upholding defensible documentation is an important step moving forward.
The OIG is looking for inaccurate documents, long and short length of stay live discharges, billing for unneeded services, visits lacking physician referrals, and the location of patients prior to hospice admission (A1802). The emphasis on patients without a prior ER visit or inpatient stay infers the audit focuses on the chronic population, for patients battling things such as dementia that don’t require an ER visit.2 Even though there are many legitimate cases, understanding 18-02 is an essential step to prepare your agency for a possible audit.
Overview of A1802
Hospice Item Set (HIS) question A1802 is used in determining hospice eligibility; it is a question of patient location prior to hospice admission. Documentation responses to A1802 include the following: general inpatient, ER visit, community resident, long-term care, or answer 99 (meaning other). Since the pandemic, many patients have been less interested in institutional care due to fears of COVID or safety restrictions limiting direct contact with family members.1 Many more hospice referrals are coming directly from physician offices with answer 99 documentation. This documentation, although legitimate, is exactly the conditions that raise red flags for OIG audits. The question of hospice eligibility is targeted most frequently in audits. The False Claims Act targets fraud, and any red flags raised will be thoroughly reviewed by the IMRC to ensure regulations and documentation are properly fulfilled.1
Although there are many legitimate cases where patients require hospice admission without a prior ER visit or inpatient stay, this practice is common in many fraudulent admission attempts. As the 2023 audit begins rollout, OIG is expected to primarily target A1802 answers where the response is not equal to inpatient event or ER Visits prior to hospice admission. Even if fraud isn’t present, improper documentation of these A1802 cases can lead to additional scrutiny from OIG. Prioritizing proper documentation is of utmost importance to guarantee operations remain at full efficiency in the coming months.
We sat down with Tom Maxwell, chairman at Maxwell Healthcare Associates to discuss the upcoming audits and key takeaways regarding A1802. He shared his insights regarding audit pattern, agency trends that raise red flags, and preemptive course of action your agency can take to prevent future challenges. Supporting these themes, his main points were as follows:
Make sure your agency is prepared
The recommended course of action as these audits rollout would be to perform a preliminary double audit on your own agency. Make sure all documentation and certifications are up to date. From there, establish validation around A1802, double-checking patients with no prior ER visit, ensuring their cases go through an extended QA process. Once self-review has been established and gaps have been identified, the lengthy process of closing said gaps and ensuring compliance begins.
Maxwell Healthcare Associates is here to help your agency consolidate efforts and close gaps, ensuring you’re up to date with compliance in the event of an OIG audit. MHA has simplified the review process to assess all patient documentation and ensure proper due diligence has been performed at the time of admission. Our experts consolidate this data, certifying that every case, especially 99 answers are documented correctly in the eyes of OIG. In the event of an audit, your agency will have all documentation prepared for a smooth transition. If you’d like to learn more about this process or receive assistance with a self-audit, contact us at [email protected] or visit www.maxwellhca.com.
1. Parker, Jim. “OIG Planning National Audit for Hospice Eligibility for 2023.” Hospice News. Hospice News, January 19, 2022. https://hospicenews.com/2022/01/19/oig-planning-national-audit-for-hospice-eligibility-for-2023/.
2. Young, Howard J. “Oig Planning Nationwide Audit of Hospice Eligibility – What You Should Know.” OIG Planning Nationwide Audit of Hospice Eligibility – What You Should Know. Morgan Lewis, January 18, 2022. https://www.morganlewis.com/blogs/healthlawscan/2022/01/oig-planning-nationwide-audit-of-hospice-eligibility--what-you-should-know.
3. “Healthcare Fraud & Abuse Annual Review 2020 - Bassberry.” Healthcare Fraud and Abuse Review 2020. Bass Berry and Sims, 2020. https://www.bassberry.com/wp-content/uploads/healthcare-fraud-abuse-annual-review-2020.pdf.