Top Payment Scrutiny Areas in Hospice Care

As more government agencies leverage data analysis and tracking to monitor billing in the home health and hospice space, providers are seeing heightened scrutiny across billing practices. From time to time, everyday mistakes in documentation and challenges with compliance can lead to bigger problems—even when providers think they are doing everything right.

In 2015, hospice payments reached nearly $16 billion, and its growing clout as a service means that watchdogs are on the lookout for fraudsters and improperly billing.

As more money is being poured into the sector, there are several “traps,” that providers can fall into that can bring about more scrutiny on their practices, according to Carrie Cooley, RN, MSN, chief executive officer of Weatherbee Resources, Inc., a hospice consulting firm that specializes in compliance with hospice regulations. Cooley spoke on hospice scrutiny at the National Hospice and Palliative Care Organization Management Leadership Conference in Washington, D.C. in April.


Here are some of the top areas where hospice is seeing more scrutiny:

Compliance department challenges

Across the industry, providers have adopted a “proceed until apprehended mentality,” according to Cooley. In other words, some providers are continuing business as usual even when their practices are not up to snuff on the compliance end. Carrying on without fully meeting requirements is a big danger to a business once their practices come under scrutiny.


Unlike the mentality of McDonald’s Founder Ray Kroc, who said, “Look after the customer and the business will take care of itself,” hospices must look after the business in order to provide quality care to patients.

Most providers who meet scrutiny think “[they] didn’t mean to mislead the government, and they don’t think they need to pay anything back,” Cooley said.

However, providers need to take a closer look at their practices and procedures to be fully compliant and to avoid being taken by surprise if an audit were to happen. Intent might not matter when it comes to following the regulations.

Billing issues

One area where hospice providers may run into trouble within billing is if employees are used to doing electronic medical record (EMR) copy-and-paste, or duplicating some entries across patient records. What might seem like a time-saver in the short term can actually be a big issue with the Office of Inspector General (OIG), which won’t be able to distinguish between a real visit and one that was simply copied.

“The problem about saving time—the OIG calls it a worthless service,” Cooley said. “When you [copy and paste], it’s difficult to tell if the visit was made or [the entry was made] just to appear [as if] a visit was made.”

When reviewers for federal agencies, which are typically contractors, are looking at hospice claims, they only have the documentation to go on, according to Cooley, which is why each claim and case needs to be distinct, well-documented, and follow all requirements.

Providers should keep in mind that reviewers are looking at clinical elegibility of patients in addition to the technical eligibility and the necessity for a higher level of care in hospice, according to Carrie.


As providers continue to see more quality reporting and data measurement requirements come into effect—and change—they need to continue checking their own reporting, particularly their PEPPER reports. These reports—Program for Evaluating Payment Patterns Electronic Report—can help hospice providers pinpoint risk areas by identifying outliers in their data, according to Cooley.

In particular, reviewers look for exceptionally long lengths of stay in hospice that exceed the 180 days of care.

To combat scrutiny and mitigate general risk, hospices can ensure they have a “robust” QAPI program, or Quality Assurance and Performance Improvement program, according to Cooley.

Target probe and educate

Last year, CMS expanded its new auditing process, targeted probe and educate (TPE), which, theoretically, should be a better process for hospices.

“It’s my opinion that TPE should be better for hospice providers,” Cooley said.

The TPE process is performed by a Medicare Administrative Contractor (MAC) that targets a specific provider or group of providers based on data. This means that most hospices likely won’t be targeted.

Providers are required to turn over a set number of claims to the MAC for review, which are then returned. If the results show a high number of improper payments, providers will have the chance to make changes and improve.

TPE goes through up to three rounds of this review process before further action is taken or agencies are cleared.

“You have to take the bull by the horns and fix it yourself,” Cooley said. “You can’t rely on a contractor to do it for you.”

Written by Amy Baxter

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