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Medicare fee-for-service programs made $31.23 of improper payments from Medicare in 2023, down from 12% in 2022, according to a new report from the U.S. The leading cause of these payments were inaccurate or incomplete documentation. The post Medicare Making Fewer Improper Payments to Hospices appeared first on Hospice News.
For the time being, Medicare Advantage may be providers’ best bet for palliative care reimbursement. Centers for Medicare & Medicaid Services (CMS) also allows Medicare Advantage plans to cover palliative care as a supplemental benefit. This year, the number of MA plans swelled to 3,998 nationwide, up 6% from 2022.
Medicare made an estimated $190 million in improper payments to acute-care hospitals for outpatient hospice services between 2017 and 2021. Our medical reviewer found that Medicare paid acute-care hospitals for outpatient services that palliated or managed hospice enrollees’ terminal illnesses and related conditions,” the OIG report stated.
Medicare claims for unrelated services creates serious financial and legal risks for hospice providers — even if they are not the ones who sent the bill. During recent years, payouts for non-hospice services provided to Medicare beneficiaries have tipped into the billions. Centers for Medicare & Medicaid Services (CMS).
Medicare Advantage plans are connecting the dots between quality scores and care delivery costs. When choosing a hospice to work with, payers in the Medicare Advantage (MA) realm zero in on providers’ quality scores and its patient population growth potential, according to Frontpoint Healthcare CEO Brent Korte.
Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently reported the results of its audit of advance care planning (ACP) billing practices among Medicare-certified physicians and other health care providers. Between 2016 to 2019, Medicare payouts for ACP totaled more than $340 million, OIG reported.
Hospice News: Today we will talk about threads of clinical documentation and satisfaction and also revenue protection. Here’s an area that you missed from a documentation perspective where you could get dinged by CMS for not documenting it, either this element or this way.” One example is a CTI. They love doing it.
A coalition of hospice and palliative care industry groups has urged lawmakers to make billing codes for telehealth available on Medicare hospice claim forms. Centers for Medicare & Medicaid Services (CMS) to develop and implement Healthcare Common Procedure Coding System (HCPCS) codes or modifiers for telehealth visits. .
A California hospice owner and a freelance marketer have been convicted of Medicare fraud, totalling $3.2 Nita Palma of Glendale, California, in 2025 purchased Magnolia Gardens Hospice through her daughter and concealed her ownership from Medicare, according to the U.S. million, and anti-kickback statute violations. Justice Department.
Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.
Centers for Medicare & Medicaid Services (CMS) in response to fraud allegations that have resulted in licensure and billing privilege revocation. court documents stated. District Court for the Central Division of California to allow for continued Medicare licensure until the fraud dispute is resolved through the U.S.
A Medicare Administrative Contractor (MAC) can deny a hospice claim for a wide range of reasons, but two types of errors stand out that can lead to a rejection. Medicare’s automated claims processing systems are designed to identify these kinds of errors. A few causes of denials are widely known.
Audits audits by Medicare Administrative Contractors (MACs) have proliferated during the past two years, including Targeted Probe and Educate (TPE) audits, as well as those by Unified Program Integrity Contractors (UPIC), Supplemental Medical Review Contractors (SMRC) and Recovery Audit Contractors (RAC). Hospices received nearly 5.4%
Centers for Medicare & Medicaid Services’ (CMS) proposed 2025 hospice rule contains clarifications on which physicians may certify patients for hospice enrollment. However, federal regulations are inconsistent as to which physicians can certify a patient as being terminally ill under Medicare.”
Centers for Medicare & Medicaid Services (CMS). CMS and its Medicare Administrative Contractors have prioritized audits for general inpatient care (GIP) stays that are longer than seven days, though CMS has no rules that limit the time patients can receive those services. Utilization overall has been declining.
Centers for Medicare & Medicaid Services’ (CMS) review and appeals process, according to CEO Greg Hagfors. The provider recently celebrated the 45th anniversary of its founding, which preceded the establishment of the Medicare Hospice Benefit. Department of Health and Human Services (HHS) due to audit-related claims denials.
While most agencies will never encounter a Targeted Probe and Educate (TPE) audit under the Centers for Medicare and Medicaid Services (CMS), prudent hospice care providers will understand the purpose and process of the TPE program in order to best prepare should they encounter an audit in the near or long term.
Centers for Medicare & Medicaid Services (CMS) is currently developing quality measures that will be included in the HOPE tool, which will replace the current Hospice Item Set (HIS). Ensuring clinicians have strong documentation and comprehensive assessment and communication skills is another key, she stated.
Centers for Medicare & Medicaid Services (CMS) is conducting a small pilot program for post-payment reviews of hospice stays that exceed 90 days. The SMRC will notify hospices under review with a statement of reasons, request for documentation as well as informational resources. billion, a rate of 12%, Noridian indicated.
Auditing types anticipated to ramp up in hospice include Targeted Probe and Educate (TPE) audits conducted by Medicare Administrative Contractors (MACS) and others involving Unified Program Integrity Contractors (UPIC), Supplemental Medical Review Contractors (SMRC) and Recovery Audit Contractors (RAC). Some of them are easy to digest.
Aside from strong documentation, insight from hospice physicians around patient conditions is a key defense in appealing audits, experts say. Careful attention to documentation is essential to avoiding potential audits by the U.S. Centers for Medicare & Medicaid Services (CMS) or other agencies. It’s not black and white.
Centers for Medicare & Medicaid Services (CMS) has issued a memo to accreditation bodies and state agencies advising surveyors to watch out for potential hospice fraud. CMS said that reviewing certain documents and information that identify key managers, services and locations is “essential.”
If the government wants to go in and take documents, [that’s] a different issue and a lot more complex. In some cases, hospices’ Medicare certification have been revoked, while others have been barred from practicing in the industry. “The vast majority of criminal cases are going to plead out. It’s a longer conversation.”
Hospices need to have solid documentation to demonstrate a patient’s need for general inpatient care (GIP) as regulatory oversight zeroes in on those services. Both types of audits focus on identifying recurrent errors on Medicare claims or billing practices that the the U.S. GIP can involve longer stays and higher costs.
Centers for Medicare & Medicaid Services (CMS) has unveiled its final 2025 hospice rule, which includes a 2.9% increase in per diem payments alongside new quality reporting measures. The increase represents an estimated $790 million rise in total hospice payments compared to Fiscal Year (FY) 2024. It is also higher than the 2.6%
Centers for Medicare & Medicaid Services (CMS) has released its first draft guidance manual for implementing the Hospice Outcomes and Patient Evaluation (HOPE) tool. The document contains introductory material. The tool is slated for an October 2025 implementation, according to the agency’s 2025 final hospice rule.
The auditing environment has heated up in the hospice industry, with inconsistencies reportedly proliferating among the various types of regulatory enforcement activity — particularly those performed by Medicare Administrative Contractors (MACs). Centers for Medicare & Medicaid Services (CMS) considers to be unusual.
Centers for Medicare & Medicaid Services (CMS) and the U.S. Modeling this documentation after CMS’ guidelines may be a key to avoiding scrutiny, he said. In recent years, the agency collected Medicare claims and associated documentation, finding issues related to beneficiary eligibility. In recent years, the U.S.
A clinician may not not have realized they were acting contrary to patients’ wishes due to insufficient training, documentation errors or process breakdowns. . They know the patient’s wishes were documented but chose to ignore them. In other instances, a health care provider acts deliberately.
Centers for Medicare & Medicaid Services (CMS). Medicare may cover CHC for as long as 24 hours a day. Claims and documentation for these services are frequently flagged for audits or medical reviews. Each day, a patient in CHC must receive a minimum of 8 hours of nursing care or nursing and aide care.
Centers for Medicare & Medicaid Services (CMS) contracts UPIC entities to conduct investigations and audits related to potential fraud, waste or abuse. Unified Program Integrity Contractor (UPIC) audits are on the rise among hospices, with some seeing penalties like reimbursement suspension or repayments.
Fraudulent or inaccurate Medicare claims cost the federal government an estimated $60 billion annually, according to a 2018 CNBC report. Medicare hospice claims represent a solid chunk, according to regulators. You hear it all the time about documentation, documentation, documentation.
Centers for Medicare & Medicaid Services (CMS) contracts UPICs to investigate instances of suspected fraud, waste and abuse. Ensuring documentation around dually eligible beneficiaries is important when it comes to hospice patients based in skilled nursing facilities, she added. Sometimes that gets a bit confusing.”
Fraudsters have bilked Medicare for millions, with some cases resulting in criminal charges and even imprisonment. Centers for Medicare & Medicaid Services (CMS) in its finalized 2024 hospice rule implemented increased penalties for hospices that fail to comply with quality reporting requirements. Additionally, the U.S.
Kevin Sarkisyan, of San Gabriel Hospice & Palliative Care, pleaded guilty to one count of conspiracy to defraud the government for his involvement in submitting false enrollment applications to Medicare that hid the “real owners of a hospice company,” according to court documents. Ghadimi is accused of misusing Medicare payments.
The Hospice and Palliative Care Association of New York State tweeted a photograph of the veto document. New York’s hospice utilization rate was the lowest in the nation in 2020 at 24% among Medicare decedents, the National Hospice & Palliative Care Organization (NHPCO) reported. Centers for Medicare & Medicaid Services (CMS).
Hospices are seeking greater clarity on updated Medicare rules that allow hospices to document a broader range of chaplain services on claims. A key factor in the CMS decision was the addition of chaplain services as a supplemental benefit within Medicare Advantage, which demonstrated a need to expand coding beyond the VA.
The resurgence of hospice program integrity scrutiny after recent media reports highlighted fraud, specifically in four states, sparked in-person visits by CMS to every Medicare-enrolled hospice, and found about 400 being considered for administrative action,” says Courtney True, BSN, RN, and Strategic Account Executive of Homecare Homebase.
Providers are increasingly relying on systems designed to improve clinical documentation, performance on quality measures and to guide business decisions. EMRs are also crucial to regulatory compliance, as many deficiencies found in surveys or audits are the result of incomplete or inaccurate documentation.
Centers for Medicare & Medicaid Services (CMS) contracts with RACs to conduct post-payment reviews designed to recover any funds that may have been overspent. Medicare hospice expenditures rise by about $1 billion annually, according to CMS. Many hospice providers express uncertainty about their ability to weather an audit.
This includes tasks like clinical documentation, a major pain point for clinicians who wish to focus more on their patients. Partnerships and affiliations can help hospices mitigate the payment reductions that will likely occur within Medicare Advantage, as health plans generally seek to negotiate for lower rates.
Centers for Medicare & Medicaid Services (CMS) has announced a second cohort for its Enhancing Oncology Model payment demonstration, as well as some updates to the program. While documents on the model do not specifically mention palliative care, several elements of the model align with that care model. Effective Jan.
Court of Appeals indicated that incomplete or inaccurate medical records, including documentation errors, may establish materiality in an FCA litigation. Materiality” generally means a misstatement or misrepresentation could have influenced Medicare’s decision to pay or deny the claim.
Centers for Medicare & Medicaid Services (CMS) honed in on hospice program integrity through a number of new regulations, including some in the agency’s 2024 hospice final rule. The regulations focused on Medicare enrollment in an effort to stifle unethical or illegal activity in the space.
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