The Office of Inspector General is charged with preventing fraud and abuse related to federal healthcare spending. Did you know that a new focus of audits are coming?
Prepare your agency for the upcoming OIG hospice eligibility audits for hospices for FY 2023. Hospice's fiscal year is October 1 through September 30 each year. Beginning October 01, 2022, the OIG will begin conducting eligibility audits. These audits are focused and targeted. The audit will be focused on beneficiary eligibility for hospice services in the absence of a recent hospital stay or encounter.
These audits are in response to compliance audits with show questions regarding a beneficiary's eligibility for utilization of the hospice benefit. The OIG does not conduct random audits. The top reason for ADR (additional determination request) is the lack of documentation to support a prognosis of six months or less. Hospice is a benefit for those who have been diagnosed with a terminal diagnosis and have been given a prognosis of six months or less to live if the disease follows its normal course.
Medicare in 2018 spent over 13.8 billion Medicare dollars for payments of patients with a length of stay greater than 180 days.
What can your agency do to prepare? First, each hospice agency should admit only those beneficiaries with the clinical documentation to support a terminal condition as outlined in the CMS Local Coverage Determination (LCDs) and additional medical documents. Meet with your admissions team and performance improvement departments to develop effective processes to ensure that the supportive information is collected during the intake, referral and admission processes.
Take a look at the certification of terminal illness processes and present the clinical data to your hospice medical director for review prior to scheduling an admission. Review the certification of terminal illness documentation by the physicians to ensure that the clinical narrative details a hospice eligible patient and includes the prognostic and attestation statements.
If clinical documentation is lacking upon referral, it is prudent to take the necessary time to collect the supporting information for the practitioners or facilities that have served the patient. If the patient was not discharged from a hospital, or seen at a local Emergency center, contact the patient's physician(s).
Take the time to build the supportive information and be prepared to be audited for admissions that are at risk (non-hospital discharge/visit) Success with this audit's focus will abide in your due diligence and following of processes. Non-compliance will be costly for the agency.
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