Posted Sunday, August 4, 2021

Be prepared to defend your claims submissions.

The Centers for Medicare and Medicaid Services (CMS) Center for Program Integrity (CPI) is claiming millions of dollars have been improperly paid to hospice agencies during its audits this spring. These CPI audits review hospice records to ensure the patients are eligible for service, the service provided is appropriate and the providers are authorized to deliver the care. The Medicare hospice benefit can be requested for beneficiaries who are expected to live 6 months or less.

The CPI audit may include thousands of agency records of patients with long lengths of stay over a period of several years. Auditors will review a select number of claims – usually a sample of 100 – to determine if documentation complies with Medicare billing requirements. CMS submits the sample to an independent medical reviewer to determine if the services met coverage, medical necessity and coding requirements. It is not uncommon for 20% of the sampled claims to fail, and failure rate can be as high as 50% of the claims undergoing review.

As a result, some agencies that have been paid tens of millions of dollars could be asked to return a significant percentage, which can total millions of dollars in claw backs. Some reasons for claims denial include:

  • Clinical record does not support terminal diagnosis
  • Physician or nurse practitioner did not conduct a required face-to-face interview with the beneficiary
  • No documentation to support hospice
  • Claim for service that CMS does not consider valuable to the beneficiary, such as a visit that is too short or one does not contain enough service

If claims are rejected during the audit, CMS can require the agency to identify, report and return money they have deemed to be improperly paid within 60 days, and to improve policies and procedures to prevent future occurrences of improper claims submissions. The hospice provider has the right of representation and can refute CMS’ findings.

A CPI audit can prove to be expensive and time consuming for a Medicare hospice provider. Call us today to find out how you can leverage our documentation experience to help your agency meet this regulatory challenge.  Please contact Corridor at 1-866-263-3795.

About Corridor

Focusing on key operational, regulatory and financial challenges, Corridor delivers solutions and deep expertise in codingclinical documentationcompliancebilling and educationSign up for our weekly newsletter to receive the most important industry updates, insights and news impacting home health and hospice.