Written by McBee experts Dawn Cheek, Director of Clinical Consulting, and Dee Geray, Senior Manager of Clinical Consulting
The Office of the Inspector General (OIG) recently posted their renewed focus on the Hospice General Inpatient (GIP) level of care WA-23-0020 (W-00-23-35897). They emphasize that the reimbursement rate for hospice GIP is the second highest daily rate that Medicare pays for hospice services for pain control or acute or chronic symptom management that cannot be managed in other settings. As an industry, we do understand that a focus on hospice GIP is always on the radar for fraud and abuse. What is interesting about this review is the sample is not hospice–focused, but hospital–focused. The selection criteria will be for “claims for enrollees who were transferred to GIP care immediately after an inpatient hospital stay for a period during which the enrollee’s inpatient stay reached or exceeded the geometric mean length of stay for the assigned diagnosis-related group”. The OIG reports these claims may be at high risk for inappropriate billing because GIP care may “exceed and enrollee’s needs or may not be provided.”
Our team queried a few hospice operations, quality and clinical managers whose programs utilize GIP routinely and receive frequent referrals from hospitals. Our question to them was whether this new OIG review changes anything they would do operationally to evaluate patients being referred. The answer was a resounding “no”.
As we read the reason for the review, there was a disconnect on the desired outcome and who is being targeted. At this time, there is no clear way for a hospice to understand which individuals would be at risk for further review as most hospices would not have data to indicate which beneficiaries are in this targeted category and generally speaking, why would the hospice care? When a referral is made, it is the hospice’s responsibility to evaluate whether the individual is terminal with a life expectancy of six (6) months. It is also the hospice’s responsibility to evaluate the appropriate level of care whether that is GIP level of care, home with continuous home care support or to the inpatient unit or place of residence on a routine level of care. Let’s consider a few other factors that may impact how the referral from the hospital to hospice is evaluated:
- The individual is actively dying and therefore moving to a different setting may impact them and their family negatively.
- The individual lives alone, has no caregiver, and has ongoing symptom management needs or is dying.
- The family does not want to bring the individual home due to their inability to provide care, lack of caregiving skills, social dynamics and their loved one is dying.
What does the hospice do in these cases? This list of scenarios is certainly not complete and does not identify any new transition issues. They do identify an ongoing gap in patient care that hospices have recognized for years. The challenge for the hospice is maintaining their relationship with the hospital while also ensuring the individual is cared for by experts in end-of-life symptom management. The goal of care is to align the enrollee with the most accurate level of health care without leading to a “win, lose” scenario between the hospital, the hospice or the patient and family. In the current state, often one entity is on the “lose” end of the outcome.
Ultimately, the hospice has the responsibility to properly evaluate the enrollee and provide care, document, and bill for the appropriate level of care based on that evaluation. There continues to be a gap in the care cycle where safe transitions for dying individuals is still an issue that we hope the OIG workplan will discover and make recommendations regarding.