Margarita M. Phillips 
Corrective actions taken by the U.S. Centers for Medicare & Medicaid Services (CMS) have reduced inappropriate fee-for-service payments by $ 27.72 billion over the past seven years. The agency identified claims for hospital outpatient care, skilled nursing facilities, home care and palliative care as the main factors contributing to inappropriate payments in fiscal year 2021 – more than 38% of l total estimate.
The most common problem leading to improper payments in hospices is, unsurprisingly, insufficient documentation to justify certification or recertification. Submission of the required inadequate or incomplete written documentation is a surefire way to get surveyors or auditors to the door of a hospice. As regulators increasingly turn to the palliative care space, providers need to ensure their documentation is airtight.
“CMS is undertaking a concerted effort to address the root causes of inappropriate payments in our programs,” said CMS administrator Chiquita Brooks-LaSure. “We intend to build on this success and learn from the lessons we have learned to ensure a high level of integrity in all of our programs. “
CMS defines “inappropriate payments” as overpayments or underpayments, or a refund when insufficient information has been provided to determine the validity of the claim. Most improper payments involve situations in which a state or vendor has missed an administrative step, according to CMS. While fraud and abuse can lead to inappropriate payments, CMS indicated that the vast majority of inappropriate payments do not constitute fraud.
Overpayments of palliative care claims increased to 7.77% in FY2020, from 6.69% in 2020. CMS indicated that this change was not statistically significant.
CMS often treats issues such as longer lengths of stay, live discharges, and repeated patient recertification for a hospice as red flags that can trigger an audit. Documentation – such as certification and recertification statements, hospice palliative care election statements, and more – is a key part of each of these processes.
In addition to being correct and complete as required, hospices must also complete the documentation within the required time frame. The documentation should accurately reflect the patient’s conditions, abilities and environment, including what caused the placement in general hospital care. Ensuring that all required signatures are accounted for is also critical to compliance.
One of the most commonly applied corrective action tools in the hospice palliative care space is the Targeted Survey and Education Audit (TPE). CMD temporarily suspended these activities during the COVID-19 pandemic, but resumed these actions in September.
The TPE program is designed to identify providers who have frequent errors on their health insurance claims or billing practices that CMS considers unusual. VSEs, typically conducted by Medicare Administrative Contractors (MACs), also focus on services that have high national error rates and pose a financial risk to Medicare, according to CMS.
The TPE process consists of up to three reviews of 20 to 40 applications per round, with one-on-one training provided at the end of each round.
Other enforcement mechanisms include the Additional Medical Examination Contractor (SRAM) exams. These contractors perform Medicaid medical examinations nationwide; Medicare part A / B; and medical equipment, prostheses, orthotics and durable supplies. claims to determine if claims meet coverage, coding, payment and billing requirements.
Medical examinations can focus on vulnerabilities identified by CMS data analysis, Comprehensive Error Rate Testing Program (CERT), professional organizations and other oversight agencies, such as the Inspector’s Office General of the US Department of Health and Human Services.
In 2020 and 2021, reviews of the appropriate use of general hospital palliative care requests were a priority for CMS regulatory reviews. In these cases, again, insufficient documentation was a significant problem.
The agency also identifies improper payments in hospices through Recovery Audit Contractor (RAC) reviews, designed to detect and correct past improper payments so that CMS and its contractors can implement actions to prevent future events.
The estimated overall Medicare FFS 2021 incorrect payment rate (claims processed July 1, 2020 through June 30, 2021) was 6.26%, a record high. This is the fifth year in a row that Medicare FFS’s incorrect payment rate has fallen below the 10% compliance threshold set in the Payment Integrity Information Act of 2019.
“CMS is committed to reducing and preventing inappropriate payments,” said Jonathan Blum, Senior Assistant Administrator and Chief Operating Officer of CMS. “It is important to understand that only a small fraction of irregular payments represents a payment that should not have been made – and an even lower percentage represents actual cases of fraud.”
