Medicare Spent $1.8 Billion for Improperly Filed Nursing Home Care

Cheryl Clark, for HealthLeaders Media , September 9, 2009

Medicare spent $1.8 billion in 2006 for hospice services for nursing home patients who did not meet requirements for that category of care, according to a new report from the Office of Inspector General.

In fact, 82% of hospice service claims for beneficiaries in nursing facilities did not meet at least one Medicare coverage requirement for that level of care. Such requirements include submittal of an "election statement," which is documentation that the beneficiary understands that hospice care is palliative rather than curative or documentation that the terminally ill beneficiary waives Medicare coverage of certain services, the report said.

"The extent to which hospices did not meet coverage requirements raises concerns about the services that Medicare is paying for and the quality of care that hospices are providing to beneficiaries during their last months of life," according to the 34-page report.

The review concluded, "CMS' current oversight procedures are inadequate" and "it must do more to ensure that hospices deliver care that meets Medicare requirements."

"Given the nature of hospices' noncompliance—which does not appear to be related to the beneficiaries' setting—these concerns extend to all Medicare beneficiaries receiving hospice care."

The OIG report found that 33% of claims were not accompanied by proper election statements, or that those statements contained "misleading language about the beneficiaries' right to revoke the election of hospice care," and return to standard Medicare care.

Also, 63% of claims did not meet plan of care requirements that include a properly detailed description of the scope and frequency of services, and did not specify intervals for review as required.

For 31% of claims, hospices provided fewer services than outlined in the beneficiaries' plans of care. For example, a common deficiency was that hospices provided services, but not as frequently as called for in the plans of care. "In the most extreme cases, there was no documentation in the medical records of any visits for a particular service."

For 4% of claims, certification that patients had a terminal illness was missing or did not meet one or more federal requirements. For example, in some cases, the certifications did not specify that the individuals' prognoses were for life expectancies of six months or less. "They were not supported by clinical information and other documentation in the medical records; or they were not signed by physicians."

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